APPROVED PRIVATE
DAY AND RESIDENTIAL
SPECIAL EDUCATION
SCHOOL PROGRAMS
PROGRAM REVIEW and
MID-CYCLE REVIEW
PROCEDURES
Private School Program
Information Package
2015-2016 School Year
MASSACHUSETTS DEPARTMENT OF
ELEMENTARY AND SECONDARY EDUCATION
Approved Private Day and Residential Special Education School Programs
Program and Mid-cycle Review Procedures
Table of Contents
Web-based Approach to Monitoring
PROGRAM REVIEW
Selected Program Review Criteria
MID-CYCLE REVIEW
Selected Mid-cycle Review Criteria
3
5 - 50
51
53 - 62
APPENDIX I
6.1/6.4 Learning Time Worksheet
8.5 Student Roster
11.4 Teacher Roster
11.5 Related Services Roster
11.6 Master Staff Roster
Form 1 - Notification/Requirements for Prior Approval of a Substantial Change Form
Form 2 - Incident Report
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
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MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
APPROVED PRIVATE DAY AND RESIDENTIAL
MONITORING PROCEDURES
As one part of its Accountability System, the Department of Elementary and Secondary Education oversees compliance
with education requirements in private day and residential special education programs through the Massachusetts Private
Special Education School Program Review System. This program oversight system addresses selected monitoring
requirements of 603 CMR 28.09, “Approval of Public and Private Day and Residential Special Education School
Programs,” and 603 CMR 18.00, “Program and Safety Standards for Approved Public or Private Day and Residential
Special Education School Programs.” The Program Review System additionally encompasses selected requirements
contained in 603 CMR 28.00, “Massachusetts Special Education Regulations,” as well as IDEA-2004, M.G.L. c. 71B and
civil rights provisions that are pertinent to Approved Private School Programs.
The Department’s approved private school program schedule of Program and Mid-cycle Reviews is posted on the
Department’s web site at http://www.doe.mass.edu/pqa/review/psr/6yrcycle.html.
Web-based Approach to Monitoring
The Department piloted a new web-based approach to comprehensive monitoring in the 2010-2011 school year.
Currently, every Program Review and Mid-cycle Review is conducted using this approach. The web-based monitoring
system (WBMS) allows both programs and the Department to submit, review and exchange documents and information
through the Department’s security portal. This new approach combines familiar elements from the standard Program
Review and Mid-cycle Review procedures in combination with new features that strengthen accountability and oversight
on a continuous basis.
Criteria: The program review criteria selected for each WBMS Program Review begins with the agency conducting a
self-assessment by private school programs across all monitoring criteria. For Mid-cycle Reviews a subset of the
monitoring criteria are self-assessed by private school programs, along with any criteria that resulted in a prior finding of
noncompliance and any new monitoring criteria. Program Quality Assurance, through its desk review procedures, then
examines the self-assessment submissions and determines which criteria will be followed up on through onsite
verification activities.
Team: Depending upon the scope of onsite activities that have been identified based on the Department’s desk review of
the agency’s self-assessment, a 2-3 member Department team will conduct a 2-3 day onsite Program Review. Mid-cycle
Review teams consist of 1-2 members and the onsite is 1-2 days.
WBMS Methods: Self-Assessment Phase: This is a requirement for all agencies participating in the web-based
monitoring system and is completed in the year prior to the onsite review.
 Agency review by private school program of documentation for required elements including document
uploads.
 Agency review by private school program of a sample of student records selected and a sample of staff
records selected.
 Upon completion of these portions of the self-assessment, it is submitted to the Department for review.
Desk Review Phase: The chairperson assigned to each agency reviews the responses by the private school program to
questions regarding the critical elements for appropriate policies, procedures, and practices, as well as actual
documents and data submissions by criteria. The student record review data, staff record review data, and explanatory
comments are examined. The outcome of this review, along with 3-year trend data from the Problem Resolution
System, and required notifications to the Department, is used to determine the scope and nature of the Department’s
onsite activities.
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Onsite Verification Phase: This includes activities selected from the following:
 Interviews of administrative, instructional, and other staff consistent with those criteria selected for onsite
verification.
 Interviews of parent representatives and other telephone interviews as requested by other parents or members
of the general public.
 Review of student records and staff records: The Department selects a sample of student and staff records
from those the agency reviewed by the private school program as part of its self-assessment to verify the
accuracy of the data. The Department also conducts an independent review of a sample of student and staff
records that reflect activities conducted since the beginning of the school year. The onsite team will conduct
this review, using standard Department procedures, to determine whether procedural and programmatic
requirements have been implemented.
 Surveys of parents of students with disabilities: Parents of students with disabilities whose files are selected
for the record review, as well as the parents of an equal number of other students with disabilities, are sent a
survey that solicits information regarding their experiences with the agency’s implementation of special
education, related services, and procedural requirements.
 Observation of classrooms and other facilities: The onsite team visits a sample of classrooms and other school
facilities used in the delivery of programs and services to determine general levels of compliance with
program requirements.
Report: The report will be based on a review of the written documentation regarding the operation of the school's
programs and the information gathered from the Onsite Verification Phase. A Draft Report of Comments will be issued
via the WBMS. Agencies may respond to the factual accuracy of the report within 10 business days.
A Final Report will then be issued via the WBMS and in hard copy. Detailed findings for each program area describe
determinations of the Department about the implementation status of each requirement (criterion) reviewed. The
Department’s Approved Private School Program Review Final Reports are posted on the Department’s web site at
http://www.doe.mass.edu/pqa/review/psr/reports/default.html and the Mid-cycle Review Reports are posted at
http://www.doe.mass.edu/pqa/review/psr/reports/followup.html.
Response to Program Review Final Report findings: Where criteria are found to be not fully implemented, the
private school program is required to propose corrective actions, within 20 business days of receipt of the final report, to
bring those areas into compliance with the respective statutes or regulations. Additionally, a program is encouraged to
incorporate any required corrective action as approved by the Department into its internal improvement plans, including
the program’s professional development plans. In Mid-cycle Reviews, after the Mid-cycle review Report is issued the
program enters progress report information directly into the WBMS for any criteria found to be not fully implemented
and for this reason no corrective action plan is created.
Program Approval: Upon issuance of the Final Report, the program will receive an updated approval status. For
programs receiving a “Full Approval,” this approval will remain in effect for three (3) years expiring on August 31st of
the third year of approval. This approval will be contingent upon continued compliance with all regulations contained
within 603 CMR 28.00, “Special Education Regulations,” and 603 CMR 18.00, “Program And Safety Standards For
Approved Public Or Private Day And Residential Special Education School Programs,” as well as the Department’s
approval of all required corrective action plans. The Department may change this approval status at any point during the
three-year period if circumstances arise that warrant such a change. For Approved Private School Programs receiving a
“Provisional Approval” or “Probationary Approval,” the Department will clearly indicate the reasons for the reduced
approval, along with timelines for compliance and an expiration date of the approval status. The Department will review
all required Corrective Action Plans and issue written determinations regarding approval or disapproval of each
corrective
action plan activity.
NOTE: For programs undergoing Program Reconstruction, Special Circumstances or Extraordinary Relief, even if the
program has substantially met all of the requirements for a Full Approval, the program will remain on Provisional
Approval until the completion of the Program Reconstruction, Special Circumstances or Extraordinary Relief process.
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MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
Approved Private School Program Review
Selected Program Review Criteria
School Year 2015-2016
AREA 1: DEMONSTRATION OF NEED AND CAPACITY
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
1.2 Program & Student
Description, Program
Capacity
28.09(2)(a)(2);
28.09(2)(b)(2, 3, 7)
REQUIREMENTS
A narrative is provided that describes:
SOURCE OF INFORMATION
Documentation:
 Written narrative addressing these requirements
Please address each item individually





Identified population of students to be served
Ages of students;
Educational characteristics;
Behavioral characteristics and
Philosophy, goals and objectives.

How each of the following educational services are implemented
for the described student population of the program:
o The content requirements of the Massachusetts Curriculum
Frameworks;
o Self-help, daily living skills;
o Social/emotional needs;
o Physical education; adapted physical education;
o Pre-vocational, vocational, and career education;
o English language support (for limited English proficient
students) and
o Other: any other specialized educational service(s) provided by
the program.

How each of the following related services is or will be provided for
the described student population of the program whose IEPs
indicate such services:
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Interviews:
 All Staff
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
o
o
o
o
o
o
o
o
o
o
o
o

SOURCE OF INFORMATION
Transportation;
Braille needs (blind/visually impaired);
Assistive technology devices/services;
Communication needs (all students including deaf/hard of
hearing students);
Physical therapy;
Occupational therapy;
Recreation services;
Mobility/orientation training;
Psychological services, counseling services, rehabilitation
counseling services, social work services;
Parent counseling and training;
Health services, medical services and
Other (e.g., music therapy, sensory integration therapy).
How the kinds of supplementary aids and services available for
students in the program is or will be provided:
o Supplementary aids and services are defined as “those aids and
services – which are not ‘specially designed instruction or
related services’ – which enable eligible students to be educated
to the maximum extent possible with non-disabled students.”
These may include aids and services that would typically be
available in a less restrictive setting, and their availability
would be helpful when the student can be placed in a less
restrictive placement (e.g., adapted text, enlarged print, graph
paper, peer tutor).
NOTE: Residential Programs reflect the 24-hour nature of the
program and indicate how residential services and educational services
will be fully coordinated.
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AREA 2: ADMINISTRATION – APPROVALS, LICENSES AND CERTIFICATES DOCUMENTATION
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
2.2 Approvals,
Licenses, Certificates
of Inspection
18.04(1);
28.09(2)(b)(5);
28.09(5) (b); 28.09(6)
(b, c)
REQUIREMENTS
The program has current licenses, approvals, and certificates of
inspection by state and local agencies.






2.3 EEC Licensure
102 CMR 3.00
(Residential
Programs only)
Safety Inspection. The program shall have an appropriate certificate
of inspection from the Department of Public Safety or the local
building inspector for each building to which students have access;
Fire Inspection. The program shall obtain a written report of an
annual fire inspection from the local fire department;
Lead paint inspection (if facility was built prior to 1978). All
buildings, residential or otherwise, utilized by children younger than
six or with a mental age younger than six shall be free of lead paint;
Local Board of Health permit if providing food services;
Asbestos inspection or date when building was constructed and
statement from appropriate authority that building is asbestos-free
(if asbestos is present, then a containment plan is necessary); and
Statement regarding the non-existence of PCBs, or, if PCBs are
present, then a containment plan.
The residential program has a current, full license from the Department
of Early Education and Care (EEC) (per 102 CMR 3.00). Approval by
EEC to operate a group care facility or a day care center (if applicable).
SOURCE OF INFORMATION
Documentation:
 Provide current copies of licenses, approvals,
and certificates of inspection
Observation:
 Posted certificates
Documentation:
 Provide copy of EEC license
Interviews:
 Executive Director/Program Director
 Residential Director
 EEC Licensing Specialist
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AREA 4: DISCLOSURE OF INFORMATION
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
4.2 Public Information
and Postings
REQUIREMENTS
SOURCE OF INFORMATION
The following information must be publicly posted:
 First aid procedures;
 Emergency procedures;
 Emergency telephone numbers;
 Current ESE approval certificate; and
 Current EEC License if applicable.
Documentation
4.4 Advance Notice of
Proposed
Program/Facility
Change
The program shall develop and implement a written procedure
describing how it notifies the Department of substantial changes within
its program and identifying the person responsible for making this
notification.
Documentation:
28.09(5)(c);
46.00; 18.00.
The program notifies the Department using the Department’s Form 1
(http://www.doe.mass.edu/pqa/sa_nr) and also notifies school districts
and parents of any new policies and procedures and/or changes in
current policies and procedures.
28.09(6)(a, b, c, d, e);
28.09(2)(b)(4)
Prior to any substantial change to the program or physical plant, the
program provides written notification of intent to change to the
Department. Notice shall be given with sufficient time to allow the
Department to assess the need for the proposed change and the effects of
such change on the educational program. The program must also
provide written notification to the Department of any sudden and/or
unexpected changes that may impact the overall health or safety of
students and/or the delivery of services required by IEPs.
NOTE: While typically a Form 1 is required for “changes made to
ESE required policies and procedures that result in continued
adherence to regulatory requirements,” for any policy changes
resulting from the changes in 603 CMR 46.00 Regulations on
Restraint and Seclusion and accompanying changes to 603 CMR
 Description of where the information is kept that
relates to this criteria
Observation:
 All required postings
 Copy of the program’s written procedures for
notifying the Department of substantial changes
within the program, including the contact person
responsible for providing such notification, in
policies and procedures manual
Form 1 Submissions:
 Have Form 1 submissions available onsite
Interviews:







Board of Directors
Executive Director
Program Director
Education Director
Residential Director
Residential Director
Director or Operations
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
4.5 Immediate
Notification
18.03(10); 18.05(7);
28.09(12) (a, b)
REQUIREMENTS
SOURCE OF INFORMATION
18.00, such policy changes will be reviewed as part of the Program
Review/Mid-cycle Review process; therefore Form 1’s should not be
submitted. Changes to ANY other policies and procedures require
the program to submit a Form 1 and obtain approval from ESE
prior to implementation.
The program shall develop and implement a written procedure
Documentation:
describing how it notifies all appropriate parties of serious incidents
 Copy of the program’s written procedures for
within the program and identifying the person responsible for making
notifying all appropriate parties of serious
this notification.
incidents, including the contact person
For ALL students (Massachusetts and Out-of-State students)
responsible for providing such notification
The program makes immediate notification to the parent, the public
school district special education administrator, and to any state agency
Student Record Reviews:
involved in the student’s care or placement (by telephone and letter), and
 All incident reports maintained in student
the Department of Elementary and Secondary Education (by telephone
records
and Form 2) of the following incidents:
 Death of a student;
Interviews:
 Filing of a 51-A report with DCF, or a complaint to the Disabled
 Board of Directors
Persons Protection Commission against the school or a school staff
 Executive Director
member for abuse or neglect of a student;
 Education Director
 Any action taken by a federal, state or local agency that might
jeopardize the school’s approval with the Department; and
 Program Director
 Any legal proceeding brought against the school or its employee(s)
 Residential Director
arising out of circumstances related to the care or education of any
 Teachers
of its students regardless of state of residency.
 Direct Care Staff
For Massachusetts Students Only:
 Public School Contact Person
 The hospitalization of a Massachusetts student (including out-patient
 State Agency Contacts
emergency room visits) due to physical injury at school or
 Parents
previously unidentified illness, accident or disorder which occurs
 Transportation providers
while the student is in the program;
 Massachusetts student injury resulting from a motor vehicle accident
during transport by school staff (including contracted staff) which
requires medical attention;
 Massachusetts student run away;
 Emergency termination of a Massachusetts student under
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
A
REQUIREMENTS

SOURCE OF INFORMATION
circumstances in which the student presents a clear and present
threat to the health
and safety of him/herself or others pursuant to 18.05(7)(d); and
Any other incident of serious nature that occurs to a Massachusetts
student.
AREA 5: ADMINISTRATION AND ADMISSION PROCEDURES
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
5.1 Student
Admissions
28.09(11);
18.05(1)(b)(1-17);
18.05(2); 18.05(3)(c)
REQUIREMENTS
The program develops and implements a written admissions policy
that includes the following:
 A statement that the program maintains a copy of its policies
and procedures manual on site;
 A statement that the program provides written notice to the
parents of the enrolled students that copies of its policies and
procedures manual are available upon request;
 Admission criteria;
 Admissions procedures;
 Information required from referring school districts as part of
the application process;
 Procedures followed to determine whether the student will be
admitted;
 (For Residential Programs Only) Procedures to prepare staff
and students in the living unit for the new student’s arrival;
 A statement that prior to admission documentation is required
from a licensed physician of a complete physical examination of
the student not more than twelve (12) months before admission;

A statement that in the event of emergency placements, the
school shall make provisions for a complete examination of the
SOURCE OF INFORMATION
Documentation:
 Copy of written admissions criteria from
policies and procedures manual
 Copy of the program’s application/intake form
used for student admissions
 Copy of the program’s narrative description of
orientation for parents and students upon
admission to the program
Interviews:








Board of Directors
Executive Director
Program Director
Education Director
Residential Director
Director of Intake/Admissions Coordinator
Intake Team Members
Nurse
 Parents
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS

5.2(a) Contracts
28.06(3)(f)
SOURCE OF INFORMATION
student within 30 days of admission; and
A statement that prior to admission, and upon request, the
Director of the program or designee will be available to the
parents, student and the public school for an interview. The
interview shall include an explanation of the school’s purpose
and services, policies regarding student and parent rights
including student records, the health program including the
procedures for providing emergency health care, and the
procedure for termination of a student. The interview will allow
for the opportunity for the student and parents to see the
facilities, meet the staff members and to meet other enrolled
students.
There shall be a written contract for each enrolled student consistent
with the requirements of 603 CMR 28.06(3)(f).
Documentation:
 Onsite verification of contracts
Written contracts: School districts shall enter into written contracts with
all out-of-district placements. Each contract shall include, but not be
limited to, the following terms:
1. The out-of-district placement shall comply with all elements of
the IEP for the student and shall provide, in writing, to the
Administrator of Special Education detailed documentation of
such compliance through completion of required student
progress reports.
2. The out-of-district placement shall allow the placing school
district to monitor and evaluate the education of the student and
shall make available, upon request, any records pertaining to the
student to authorized school staff form the school district and
the Department in accordance with 603 CMR 23.00: Student
Records
3. The out-of-district placement shall allow the placing school
district and/or the Department to conduct announced and
unannounced site visits and to review all documents relating to
the provision of special education services to Massachusetts
students at public expense. Access to documents for the placing
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
SOURCE OF INFORMATION
school district shall include general documents available to the
public, documents specifically related to the student placed by
such district, and other documents only to the extent they are
necessary to verify and evaluate education services provided at
public expense.
4. The out-of-district placement shall afford publicly-funded
students all the substantive and procedural rights held by
eligible students, including but not limited to those specified in
603 CMR 28.09, and shall comply with all other applicable
requirements of 603 CMR 28.00 and applicable policy
statements and directives issued by the Department.
5. No school district shall contract with any out-of-district
placement that discriminates on the grounds of race, color, sex,
gender identity, religion, national origin, sexual orientation,
disability or homelessness.
AREA 6: EDUCATIONAL PROGRAM REQUIREMENTS - STUDENT LEARNING TIME
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
6.1 Daily Instructional
Hours
603 CMR 27.04
REQUIREMENTS
The program ensures that each student is scheduled to receive an
average minimum of the following instructional hours unless otherwise
approved by ESE or a student’s IEP provides otherwise:
 Elementary – A total of:
10 month program – 900 hours
11 month program – 990 hours
12 month program – 1080 hours
 Secondary – A total of:
10 month program – 990 hours
11 month program –1089 hours
SOURCE OF INFORMATION
Documentation:
Learning Time Worksheet
 Block schedule that includes:
o Beginning and ending time for each
instructional block;
o Subject area for each block;
o All non-instructional time (e.g. lunch,
recess, transitions between classes, etc.,.);
and
o If non-instructional time activities are
counted as instructional hours, they must
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
12 month program – 1188 hours
The program ensures that, unless a student’s IEP provides otherwise,
each elementary school student is scheduled for at least 900 hours of
structured learning time a year and each secondary school student is
scheduled for at least 990 hours of structured learning time a year
(including physical education for all students, required by M.G.L. c. 71,
§ 3), within the required school year schedule. Where the private special
education program operates separate middle schools, at the beginning of
the school year it designates each one as either elementary or secondary.
NOTE: The program ensures that its structured learning time is time
during which students are engaged in regularly scheduled instruction,
learning or assessments within the curriculum of core subjects and other
subjects as defined in 603 CMR 27.02. The program’s structured
learning time may include directed study (activities directly related to a
program of studies, with a teacher available to assist students);
independent study (a rigorous, individually designed program under the
direction of a teacher, assigned a grade and credit); technology-assisted
learning; presentations by persons other than teachers; school-to-work
programs; and statewide student performance assessments.
6.1(a) Physical
Education
Requirements
The program shall have a written plan to teach physical education as a
required subject at all grade levels for all students for the purpose of
promoting the physical well being of students.
M.G.L. c. 71, § 3
NOTE: Physical education classes are to be considered part of the
student’s structured learning time.
SOURCE OF INFORMATION
be specified in student’s IEPs.
 Calculation of the total number of instructional
hours per year with documentation of how total
was determined
Interviews:
 Education Director
 Teachers
 Related Service Providers
 Direct Care Staff
Documentation:
 Copy of program’s written plan that describes
the implementation of the physical education
requirements and program offered to students
 Submission of written schedules that clearly
indicate when and how often physical education
classes are provided to students
Interviews:
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
SOURCE OF INFORMATION
 Program Director
 Education Director
 Physical Education/APE Teacher
6.4 School Days Per
Year
603 CMR 27.05(2);
28.09(9)(a)
All programs are run for the following minimum number of days
(exclusive of weekends, holidays, vacations):
 10 month program - 180 days
 11 month program – 198 days
 12 month program – 216 days
Before the beginning of each school year, the program sets a school year
schedule for each program. This schedule must include at least five
additional school days to account for unforeseen circumstances (i.e.,
snowstorms).
NOTE: All programs must schedule the number of school days per
ESE’s application approval plus five additional days for unforeseen
circumstances.
Documentation:
 Copy of school calendar for school year clearly
indicating number of scheduled days
o The last day of school must be indicated
o Five additional school days to account for
unforeseen circumstances must be indicated
o The last day of school must be indicated for
high school seniors
Interviews:
 All Staff
AREA 8: EDUCATIONAL PROGRAM REQUIREMENTS - INDIVIDUALIZED EDUCATION PROGRAMS
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
8.4 Program
Modifications and
Support Services for
English language
learners (ELLs)
REQUIREMENTS
The program shall develop a written plan to implement necessary
program modifications and support services to identify and effectively
serve English language learners (ELLs). Such program modifications
and support services comply with applicable state law (M.G.L. c. 71A)
and federal law (Title VI).
SOURCE OF INFORMATION
Documentation:
 Copy of written plan addressing how to
effectively serve English language learners
(ELLs)
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
M.G.L. c. 71A; Title
VI
REQUIREMENTS




8.5 Current IEP &
Student Roster
28.09(5)(a)
The program must acknowledge it is responsible to serve ELLs.
The program must affirm its willingness to accept students with
ELLs into its program.
The student must be afforded the same opportunity to access and
participate in the program’s services, activities and other
benefits as all other students.
Unless the student’s IEP specifies otherwise, the student must
receive:
o sheltered content instruction from a trained and
qualified teacher; and
o additional instruction in English as a Second Language
by a certified ESL teacher.
The program has on file a current IEP for each enrolled Massachusetts
student that has been issued by the responsible public school district and
consented to and dated by the student’s parent(s) (or student, when
applicable).
SOURCE OF INFORMATION
Student Record Reviews:
 IEPs of ELL students contain required
documentation
Documentation:
Student Roster Form
 A roster of publicly funded Massachusetts
students currently enrolled in the program
containing the following information:
o Each student’s initials (not name);
o The school district responsible for preparing
the student’s IEP;
o The name of the school district contact
person for each student;
o The agency(ies) supporting any part of the
student’s tuition;
o The portion of tuition supported by such
agency(ies);
o The implementation date of the most
recently issued and consented to IEP;
o The date of expiration for the most recently
issued and consented to IEP;
o The date of parental signature on the most
recently issued and consented to IEP; and
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
SOURCE OF INFORMATION
o
For each unsigned IEP,
evidence/documentation of efforts and/or
steps taken for the public school district to
obtain signed IEPs
Student Record Reviews:
 Current IEPs of students
Interviews:
 Education Director
 Teachers
 Parents
 Public School Contact Person
8.8 IEP – Progress
Reports
28.07(3);
34 CFR
300.320(a)(3)(i, ii)
Progress Reports and Content
 Parents receive reports on the student’s progress towards
reaching the goals set in the IEP at least as often as parents are
informed of the progress of students without disabilities;
 Progress Report information sent to parents includes written
information on the student’s progress toward the annual goals in
the IEP; and
 The program shall send copies of progress reports to the parents
and public school.
NOTE: IEP must contain a description of:
 How the child's progress toward meeting the annual goals will be
measured; and
 When periodic reports on the progress the child is making toward
meeting the annual goals (such as through the use of quarterly or
other periodic reports, concurrent with the issuance of report cards)
will be provided.
Documentation:
 Copy of IEP progress report form used by the
program addressing these requirements
 Description of how the program documents that
parents, school districts and/or agencies receive
copies of progress reports
Student Record Reviews:
 Completed, dated progress report that includes
the required narrative
 Evidence of when and to whom the school sent
copies of progress reports
Interviews:
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
SOURCE OF INFORMATION
 Education Director
 Teachers
 Related Service Providers
 Parents
 Public School Contact Person
 State Agency Contact
AREA 9: EDUCATIONAL PROGRAM REQUIREMENTS - STUDENT DISCIPLINE AND BEHAVIOR SUPPORT
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
9.1 Polices and
Procedure for
Behavior Support
603 CMR 46.00
REQUIREMENTS
SOURCE OF INFORMATION
The program develops and implements a written behavior support policy Documentation:
and procedures consistent with new regulations under 603 CMR 46.00
 Copy of written policies on Behavior Support
regarding appropriate responses to student behavior that may require
immediate intervention.
Interviews:
Behavior support policies shall be reviewed annually and be provided to  All Staff
program staff and made available to parents of enrolled students. The
behavior support policies shall include:
1 Methods for preventing student violence;
2 Methods for preventing self-injurious behavior and suicide;
3 A description and explanation of the program’ alternatives to
physical restraint;
4 A description of the program’s training requirements for staff;
5 A description of the program’s reporting requirements and
follow-up procedures;
6 A description including timelines of the program’s procedure for
receiving and investigating complaints regarding behavior
support policies;
7 A description of the procedures to be followed for implementing
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
8
9
SOURCE OF INFORMATION
the behavior support reporting requirements;
A description of the program’s procedure for making both oral
and written notification to the parent; and
A procedure for the use of time-out
NOTE: Meals shall not be withheld as a form of punishment or
behavior management. No student shall be denied or unreasonably
delayed a meal for any reason other than medical prescriptions.
9.1(a) Student
Separation Resulting
from Behavior
Support
603 CMR 46.01
NOTE: Behavior support training must be provided to all program staff
within the first month of the school year regarding the behavior support
policies and the requirements when such procedures are implemented;
OR
For employees hired after the school year begins, behavior support
training must be provided and completed within one month of the date
of hire of the employee.
If the program’s behavior support policy and procedures result in a
student separating from the group or program activities, it shall include:
1 Requirement that students shall be continuously observed by a
staff member and staff shall be with the student or immediately
available to the student at all times;
2 A procedure for obtaining principal approval of time-out for
more than 30 minutes based upon the individual student’s
continuing agitation; and
3 Time out shall cease as soon as the student has calmed
Documentation:
 Copy of written policies and procedures
regarding behavior management specific to
student separation
Student Record Reviews:
 Documentation related to Criterion
9.1(a) maintained in student
records or time out log of all students
Interviews:
 All Staff
9.4 Physical Restraint
The program shall have a written policy on the use of physical restraint
and administer physical restraint in accordance with the requirements of
603 CMR 46.00.
Documentation:

Copy of written physical restraint policies
and procedures;
 Onsite review of record of restraints for the
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
18.05(5);
603 CMR 46.00
REQUIREMENTS
The program administers physical restraint only in emergency situations
of last resort when needed to protect a student and/or member of the
school community from assault or imminent, serious, physical harm and
with extreme caution in order to prevent or minimize any harm to the
student as a result of the use of physical restraint.
Physical restraint policies and procedures must include the following:
1 Methods for engaging parents and students in discussions about
restraint prevention and use;
2 A description and explanation of the method of physical
restraint used by the program in an emergency situation;
3 A statement prohibiting seclusion, medication restraint,
mechanical restraint and prone restraint unless permitted under
603 CMR 46.03(1)(b),;
4 Physical restraint shall be used only in emergency situations of
last resort, after other lawful and less intrusive alternatives have
failed or been deemed inappropriate;
5 A description of the program’s procedure for conducting
periodic review of data and documentation on the program’s use
of restraint;
6 A description of the program’s training requirements for all
staff;
7 A description of the intensive training for staff who serve as
restraint resources for the program;
8 Reporting requirements and follow-up procedures for reports to
parents/guardians and to the Department;
9 A procedure for receiving and investigating complaints
regarding restraint practices; and
10 The director or his/her designee shall maintain an on-going
record of all instances of physical restraint, which shall be made
available for review by the Department upon request
SOURCE OF INFORMATION
current school year; and
Names of staff who serve as restraint
resources within the program and evidence of
their intensive training

Student Record Reviews:

Associated restraint reports filed with the
Department of Elementary and Secondary
Education when a restraint results in the
injury of a student requiring medical
attention
Staff Record Reviews:


Associated restraint reports filed with the
Department of Elementary and Secondary
Education when a restraint results in the
injury of a staff requiring medical attention
Copies of individual student reviews for
students who were restrained multiple time
in the same week
Interviews:

All Staff
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
NOTE: A residential educational program must comply with ESE
restraint requirements under 603 CMR 46.00 during school hours and
EEC restraint requirements under 102 CMR 3.00 during residential
hours.
NOTE: A program within a program or facility subject to M.G.L. c. 123
or Department of Mental Health Regulations must comply with the
restraint requirements of M.G.L. c. 123, 104 CMR 27.12 or 104 CMR
28.05, where applicable.
NOTE: Physical restraint training must be provided to all program staff
within the first month of the school year regarding restraint prevention
and the requirements when restrain is used;
OR
For employees hired after the school year begins, physical restraint
training must be provided and completed within one month of the date
of hire of the employee
9.6 10+ Day
The program shall develop and implement the following procedures
Suspensions
when suspensions constitute a change of placement. A suspension is a
change of placement when: 1) it exceeds 10 consecutive school days or
34 CFR 300.530 – 537 2) it is one of a series of suspensions that constitute a pattern under 34
18.05(7)
CFR 300.536.
 A request is made of the student's responsible school district to
convene an IEP Team meeting prior to a suspension that constitutes a
change in placement of a student with disabilities.
 The program participates in the TEAM meeting:
o To develop or review a functional behavioral assessment of the
student’s behavior and to develop or modify a behavior
intervention plan;
o To identify appropriate alternative educational setting(s); and
o To conduct a manifestation determination (i.e. to determine the
relationship between the disability and the behavior).
SOURCE OF INFORMATION
Documentation:
 Copy of written suspension policies and
procedures
 Onsite review of tracking mechanism of
suspensions
Student Record Reviews:



Documentation regarding tracking the number
and duration of suspensions, as well as
notification of all appropriate parties, is
maintained in student records or a copy of the
student suspension log
Documentation of notification to parents,
school districts and other appropriate parties
are maintained in student records
Evidence of IEP Team meetings, notices and
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
SOURCE OF INFORMATION
 If the TEAM determines that the behavior is NOT a manifestation of
the disability, the school may suspend or terminate the student
consistent with policies applied to any other student in the program.
The responsible school district must, however, offer an appropriate
education program to the student that may be in some other setting.
meeting notes, revised IEP, manifestation
determination, behavioral intervention plan
and/or functional behavioral assessment if
applicable
 If the TEAM determines that the behavior IS a manifestation of the
disability, the TEAM, takes steps to modify the IEP, the behavior
intervention plan, and/or the placement.
NOTE: Sending a student home “early” or an in-school suspension of a
student who is not receiving instruction from either a licensed teacher or
a paraprofessional who is being supervised by a licensed teacher is
considered a suspension if the student’s IEP does not allow for the
modification of learning time requirements of the Board of Elementary
and Secondary Education.
9.7 Terminations
18.05(7); 28.09(12)(b)
The program develops and implements a written termination policy that
includes provisions regarding both Planned Terminations and
Emergency Terminations.
The policy must include the following:
a) Planned Terminations: The program shall notify the public school
district of the need for an IEP review meeting and provides notice of this
meeting to all appropriate parties ten (10) days in advance of the
intended date of the meeting. The purpose of the meeting will be to
develop a clear and specific termination plan for the student that shall be
implemented in no less than thirty (30) days unless all parties agree to an
earlier termination date.
b) Emergency Terminations: In circumstances where the student
presents a clear and present threat to the health and safety of him/herself
or others, the program shall follow the procedures required under 603
Interviews:
 Program Director
 Education Director
 Residential Director
 Clinical Director
 Teachers
 Related Services Providers
 Direct Care Staff
 Public School Contact Person
 State Agency Contacts
 Parents
Documentation:
 Copy of written termination policy that clearly
delineates between planned and emergency
terminations
Student Record Reviews:
 Evidence of notice to school districts prior to
termination;
 Evidence of notification to parents and the
Department of the emergency termination; and
 Meeting minutes or documentation from the
Team meeting regarding termination
Interviews:
 Board of Directors
 Program Director
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
CMR 28.09(12)(b) and immediately notify the Department of
Elementary and Secondary Education.
The program shall not terminate the enrollment of any student, even in
emergency circumstances, until the enrolling public school district is
informed and assumes responsibility for the student. At the request of
the public school district, the program shall delay termination of the
student for up to two calendar weeks to allow the public school district
the opportunity to convene an emergency Team meeting or to conduct
other appropriate planning discussions prior to the student's termination
from the special education school program. With the mutual agreement
of the program and the public school district, termination of enrollment
may be delayed for longer than two calendar weeks.
SOURCE OF INFORMATION
 Education Director
 Residential Director
 Clinical Director
 Teachers
 Direct Care Staff
 Public School Contact Person
 State Agency Contacts
 Parents
AREA 10: EDUCATIONAL PROGRAM REQUIREMENTS - RATIOS
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
10.1 Staffing for
Instructional
Groupings
28.06(6)(d);
28 09(7)(e)
REQUIREMENTS
The program shall have instructional groupings that do not exceed 1) the
approved ESE Student: Licensed Educator Ratio and 2) the approved
ESE Student: Licensed Educator and Aide Ratio.
SOURCE OF INFORMATION
Documentation:
 Documentation that indicates the most recent
ESE approved Student: Licensed Educator Ratio
through either Initial Application, Program
Student: Licensed Educator Ratio is defined as the number of licensed
Reconstruction letter, Extraordinary Relief
special education teachers, licensed regular education teachers or
Letter, or Form 1 notification
licensed related service providers to the number of students within an
 Documentation that indicates the most recent
instructional group.
ESE approved Student: Licensed Educator and
Aide Ratio through either Initial Application,
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
Student: Licensed Educator and Aide Ratio is defined as the number of
licensed special education teachers, licensed regular education teachers
or licensed related service providers, and the number of aides (teacher
aide, paraprofessional, direct care staff, behaviorist) to the number of
students within an instructional group.
SOURCE OF INFORMATION
Program Reconstruction letter, Extraordinary
Relief Letter, or Form 1 notification
 Block schedules that clearly display the numbers
and initials of students, and the numbers and
initials of certified educators and aides in all
classrooms for all periods throughout the school
day. Indicate on the schedule if staff are licensed
educators or aides
Observations:
 Classroom observation of student: licensed
educator ratios and student: licensed educator
and aide ratios
Interviews:





10.2 Age Range
28.06(6)(f, g)
The program shall ensure that the ages of the youngest and oldest child
in any instructional grouping shall not differ by more than forty-eight
months (4 years).
Prior to exceeding the forty-eight month timeframe, an Alternate
Compliance Waiver (http://www.doe.mass.edu/pqa/sa_nr) must be
requested and approved by the Department.
Program Director
Education Director
Teachers
Direct Care Staff
Parents
Documentation:
 Block schedules for every classroom and every
period indicating the initials of students with
corresponding dates of birth
 Alternate Compliance Waiver, if applicable
Interviews:





Program Director
Education Director
Teachers
Direct Care Staff
Parents
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AREA 11: EDUCATIONAL STAFFING REQUIREMENTS - STAFF POLICIES
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
11.1 Staff Policies and
Procedures Manual
18.05(11);
18.05(11)(c)(1);
28.09(7);
28.09(11)(a);
M.G.L. c. 71, § 38R;
ESE Advisory on
CORI revised 5/7/07;
603 CMR 26.00 as
amended by Chapter
199 of the Acts of
2011
11.2 Administrative
Responsibility
18.05(11)(a, b)
REQUIREMENTS
SOURCE OF INFORMATION
The program shall develop and implement a written staff policies and
procedures manual that describes:
 Criteria and procedures for hiring. This should include the school’s
Criminal Offender Record Information (CORI) policy regarding
CORI checks on employees, volunteers and transportation providers
whose responsibilities bring them into direct and unmonitored
contact with students (upon initial hire and every three years
thereafter). [NOTE: A residential program licensed by EEC does
not need to conduct independent CORI checks where those checks
have been done through EEC];
 Procedures for evaluation of staff;
 Procedures for discipline of staff (including suspensions and
dismissals);
 Procedures for handling staff complaints (See Criterion 15.8);
 A plan for using volunteer and/or intern services; and,
 Statement of equal employment/educational opportunities in regard
to race, color, sex, gender identity, religion, national origin, sexual
orientation, disability or homelessness.
Documentation:
 Staff policy and procedures manual
The program shall designate one person who will have administrative
responsibility over the operation of the program. Programs with more
than 40 professional licensed staff may have one (or more) assistant
administrator(s) provided the Department approves such positions.
Documentation:
The administrator or designee shall at all times be on the premises of the
school while the program is in operation. All staff on duty shall know
who is responsible for administration of the program at any given time.
Staff Records Reviews:
 Staff performance evaluations are scheduled and
written copies maintained in the staff records for
all staff as outlined in the program’s staff policy
and procedures manual
 Evidence of completed CORI checks prior to
initial hire and every three years thereafter
Interviews:
 Board of Directors
 Director of Human Resources/Staff
Administrator
 All Employees
 Name of designated administrator and assistant
administrators, if applicable
Interviews:
 Board of Directors
 Executive Director
 Assistant Director(s)
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
11.3 Educational
Administrator
Qualifications
28.09(5)(a);
28.09(7)(a);
603 CMR 44.00
REQUIREMENTS
At least one staff member shall be designated as the educational
administrator for the program. Such person shall be assigned to
supervise the provision of special education services in the program and
to ensure that the services specified in each student’s IEP are delivered.
The educational administrator shall either possess licensure as a special
education administrator or possess all of the following:
 License as a special educator;
 A minimum of a master's degree in special education or a
related field; and
 A minimum of one year of administrative experience.
The educational administrator shall be re-licensed pursuant to the
requirements of 603 CMR 44.00.
The educational administrator shall obtain supervisory approval of
his/her Professional Development Plan per 603 CMR 44.04, if
applicable.
SOURCE OF INFORMATION
Documentation:
 Name of educational administrator(s)
and, either
 Copy of licensure as a special education
administrator
or ALL of the following:
 Copy of ESE license as a special educator or
copy of ELAR activity sheet; and,
 Evidence of Master’s Degree in special
education or a related field; and
 Evidence of a minimum of one year of
administrative experience (acceptable
documentation includes a current resume)
Staff Record Reviews:
 Professional Development Plan
Interviews:
 Board of Directors
 Executive Director
 Program Director
 Education Director
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
11.4 Teachers
(Special Education
Teachers and General
Education Teachers)
18.05(11)(f);
28.09(5)(a);
28.09(7)(b, c); 34
CFR 300.321
REQUIREMENTS
The program must ensure that all teaching staff have teaching licenses
appropriate to meet the needs of the population being served pursuant to
the requirements of 603 CMR 7.00 and, additionally, must adhere to the
following requirements:
 All teaching staff shall be re-licensed pursuant to the requirements
of 603 CMR 44.00 including obtaining supervisor approval of
Professional Development Plans pursuant to 603 CMR 44.04, if
applicable.
 To the extent that teaching staff is providing special education
services, such services shall be provided, designed, or supervised by
a special educator.
 A program’s teacher who has knowledge about the education and
learning progress of the student must be in attendance at the IEP
meeting for the student.
At least half of the teaching staff shall be licensed in special education
areas appropriate to the population served at the program; other teaching
staff may be licensed in other educational areas, in order to provide for
content expertise in the general curriculum. The Department of
Elementary and Secondary Education may require a higher proportion of
licensed special educators if, in the opinion of the Department, the
population requires more specialized services.
The number of special education teachers and the number of the general
education teachers must correspond with the most recent approved ESE
budget.
SOURCE OF INFORMATION
Documentation:
Teacher Roster Form
 Provide a statement regarding the most recent
Department-approved number of special
education teachers and general education
teachers
 Current teaching staff roster that includes all
UFR 115’s special education teachers and UFR
116’s general education teachers in the program
that contains the following information:
o UFR#;
o Name;
o Position title within the program;
o Grade level(s) taught;
o Subject(s) taught;
o Massachusetts teaching license title, type,
grade level, number and expiration date;
o Copy of license or most current ELAR
activity sheet;
o In instances where teachers do not hold
Massachusetts licensure for the area in
which they are employed, a copy of a
current certification waiver is provided or
ELAR activity sheet;
o In instances when general education teachers
are providing special education services, the
name and license of the special educator
providing supervision; and
o Most recent date of Professional
Development Plan for special education
teachers and general education teachers with
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
SOURCE OF INFORMATION
professional level licensure.
Staff Record Review:
 Professional Development Plan
Interviews:
 Education Director
 All Teachers
11.5 Related Services
Staff
All staff providing or supervising the provision of related services
(including consultants) shall be appropriately certified, licensed or
registered in their professional areas.
28.09(7)(d)
Documentation:
Related Services Provider Form
 A current roster for all related service providers
that includes each provider’s
o UFR #;
o Name;
o Position title within program; and
o License number and/or Massachusetts State
Board of Registration number.
 Copy of License and/or Massachusetts, State
Board of Registration
Interviews:






11.6 Master Staff
Roster
The program maintains a master list of ALL staff for every position
within the program. The staff positions shall correspond to the last
Department-approved Program Budget. This list must include job titles
Executive Director
Education Director
Clinical Director
Clinicians
Nurse
Related Service Providers
Documentation:
Master Staff Roster Form
 Copy of the last approved Program Budget
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
28.09(7)
REQUIREMENTS
along with their corresponding UFR title numbers and full-time
equivalents (FTE’s). This list may include, but is not limited to:
 Administrators
 Special education teachers
 General education teachers
 Related service providers
 Registered Nurses
 Direct care workers
 Direct care supervisors
 Clerical and maintenance staff
 Psychologists
 Social workers
 Food service staff
 Consultants
Any changes/discrepancies from the last Department-approved
Program Budget (through Initial Application, Extraordinary Relief,
Special Circumstances, Program Reconstruction) must be noted.
11.9 Organizational
Structure
The program shall demonstrate that its organizational structure provides
for the effective and efficient operation of the school, supervision of
school staff, and supervision of students.
28.09(7)
SOURCE OF INFORMATION
 A current master staff roster that includes for
each staff person
o
Corresponding UFR#s
o
UFR tittles
o
Full time equivalents (FTEs)
o
Position title
o
First and Last name
o
Vacancies indicated
o Justification for any discrepancies from last
approved program budget
Interviews:




Board of Directors
Executive Director
Program Director
Director of Human Resources/Staff
Administration
 Director of Operations
Documentation:
 Submission of organizational chart that illustrate
and describe lines of supervision for staff and
students
o Organizational charts must include the
program position titles for all staff
Interviews:
 Board of Directors
 All Staff
11.12 Equal Access
Mass. Const. amend.
The program provides all students with equal access to services,
facilities, activities and benefits regardless of race, color, sex, gender
identity, religion, national origin, sexual orientation, disability or
Documentation:

Equal Access policy
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CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
Art. 114; M.G.L. c.
76, § 5; 603 CMR
26.00 as amended by
Chapter 199 of the
Acts of 2011; Title
VI: 42 U.S.C. 2000d;
34 CFR 100.3(a), (b);
Title IX: 20 U.S.C.
1681; 34 CFR 106;
Section 504: 29
U.S.C. 794; 34 CFR
104; Title II: 42
U.S.C.12132; 28 CFR
35.130; NCLB: Title
X, Part C, § 721.
REQUIREMENTS
homelessness.
1. The program provides equal opportunity for all students to participate
in intramural and interscholastic sports; and
2. Extracurricular activities or clubs sponsored by the program do not
exclude students on the basis of race, color, sex, gender identity,
religion, national origin, sexual orientation, disability or homelessness.
SOURCE OF INFORMATION

List of intramural and interscholastic sports
offerings, extracurricular activities and clubs
sponsored by the program as well as
requirements for participation in each of these
activities

List and location of any separate facilities,
activities or services provided on the basis of
any other protected category (race, color, sex,
gender identity, religion, national origin, sexual
orientation, disability or homelessness), with
narrative explaining reason for separation and
confirming comparability
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AREA 12: EDUCATIONAL STAFFING REQUIREMENTS – STAFF TRAINING
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
12.1 New Staff
Orientation and
Training
18.05(11)(g, i);
28.09(7)(f)
12.2 In-Service
Training Plan and
Calendar
28.09(7)(f);
28.09(9)(b);
28.09(10);
18.03(3);
18.05(9)(e)(1);
18.05(10);
18.05(11)(h)
Title VI: 42 U.S.C.
2000d; 34 CFR 100.3;
EEOA: 20 U.S.C.
1703(f); Title IX: 20
REQUIREMENTS
SOURCE OF INFORMATION
The program shall develop and implement a written plan for new staff
Documentation:
orientation and training that is consistent with the needs of the student
 Name of person responsible for coordination and
population and includes an orientation-training program which includes
implementation of orientation training
the following:
 Program’s philosophy
 Copy of written orientation and training program
 Organization
for new staff
 Program
 Practices
Staff Record Reviews:
 Goals
 Staff orientation verification
 ESE required topics (12.2 a-e)
 Provisions for orientation of intern, volunteers or others who
Interviews:
work at the program, if applicable.
 All Staff
NOTE: New staff may not be assigned direct care duties with students
until they have participated in all mandated trainings listed under
criterion 12.2 a-e through their orientation program.
All staff, including new employees, interns and volunteers, must
Documentation:
participate in annual in-service training on average at least two hours per
 The name and job description for the staff
month.
person responsible for the development and
The following topics are required in-service training topics and must be
implementation of the in-service training
provided annually to all staff:
program/calendar
a. Reporting abuse and neglect of students to the Department of
 Annual detailed in-service training plan. This
Children and Families and/or the Disabled Persons Protection
plan must reflect a minimum of:
Commission;
o 20 training hours for a 10 month program, or
b. Disciplinary and Behavior Management Procedures used by the
o 22 training hours for an eleven month
program
program, or 24 training hours for a twelve
c. Runaway policy;
month program,
d. Emergency procedures including Evacuation Drills and Emergency
and
Drills; and
o All training topics provided;
e. Civil rights responsibilities (discrimination and harassment)
o The name and job title of the person
regarding race, color, sex, gender identity, religion, national origin,
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 30 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
U.S.C. 1681; 34 CFR
106.31-106.42;
M.G.L. c. 76, § 5;
603 CMR 26.00 as
amended by Chapter
199 of the Acts of
2011
REQUIREMENTS
sexual orientation, disability or homelessness.
The following additional topics are required in-service training topics
and must be provided annually to all teaching staff:
 How the learning standards of Common Core Standards are
incorporated into the program’s instruction;
 Procedures for inclusion of all students in Massachusetts
Comprehensive Assessment System (MCAS) and/or Partnership for
Assessment of Readiness for College and Careers (PARCC) testing
and/or alternate assessments; and
 Student record policies and confidentiality issues.
The following additional topics are required in-service training topics
and must be provided annually to appropriate staff based on their job
responsibilities:
 CPR training and certification;
 Medication (including, but not limited to, administration of
antipsychotic medications and discussions of medications students
are currently taking and their possible side effects);
 Transportation safety (for staff with transportation-related job
responsibilities); and
 Student record policies and confidentiality issues (for staff who
oversee, maintain or access student records).
SOURCE OF INFORMATION
conducting the individual training sessions;
o The audiences to whom the training will be
offered (i.e., special education teachers, direct
care staff, social workers and
volunteers/interns);
o The dates and times when the various training
topics will be offered;
o The length of time allotted for each topic (i.e.,
two hours, ½ day); and
o Plans for outside training opportunities (i.e.,
MAAPS Conference, conferences on autism,
etc.).
 Description of how program tracks and records
individual staff attendance at trainings
Onsite Verification:
 Evidence of attendance at required trainings for
staff chosen for staff file record review
 Documentation of staff training may include staff
attendance sign-in sheet, data base chart, log or
individual employee record
Interviews:
 All Staff
12.2(c) Required
TrainingCPR Certification
18.05(9)(e)
The program shall develop and implement a training plan for CPR
Certification, which identifies:

the staff positions/titles of staff to be trained;

how many staff in each position/title will be trained; and

the frequency of CPR training and certification.
Documentation:
 A copy of the training plan
 The name and qualifications of the certified
instructor providing the CPR training
 List of staff who are CPR trained, their position
and expiration date of their current CPR
certification
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 31 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
SOURCE OF INFORMATION
Interviews:






Executive Director
Program Director
Education Director
Residential Director
Nurse
Designated CPR Certified Staff
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 32 of 63
AREA 13: PHYSICAL FACILITY AND EQUIPMENT REQUIREMENTS
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
13.2 Description of
Physical Facility
18.04; 28.09(8)
REQUIREMENTS
SOURCE OF INFORMATION
Kitchen, Dining, Bathing/Toilet and Living Areas:
Observation:
The private special education program shall ensure that all kitchen,  Observations of all physical facilities
dining, bathing/toilet and living areas are of an adequate type, size and
design appropriate to the ages and needs of the students. The program Interviews:
shall also:
 All Staff
 Maintain areas which are clean, well ventilated and free from  Parents
hazards;
 Provide students with equipment, supplies and materials (e.g.,
kitchen equipment, dining utensils, toilets, sinks, individual furniture
and storage space) which are clean, safe, safely stored, well
maintained and appropriate to the ages and needs of the students;
 Design all living areas to simulate the functional arrangements of a
home and to encourage a personalized atmosphere for small groups
of students, unless the school can justify that another arrangement is
necessary to serve the particular needs of the students enrolled in the
school.
Classroom Space:
Each room or area that is utilized for the instruction of students shall be
adequate with respect to the number of students, size and age of students
and students’ specific educational needs, physical capabilities and
educational/vocational activities.


Additionally, all programs must: Ensure that all areas, including
but not limited to, floors, ceilings and walls, are clean, well
maintained and free from safety hazards; and
Designate space separate from classroom areas for administrative
duties and staff or parent conferences.
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 33 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
13.4
Physical
Facility/Architectural
Barriers
18.04(8); Section 504:
29 U.S.C. 794; 34
CFR 104.21,104.22;
Title II: 42 U.S.C.
12132; 28 CFR
35.149, 35.150; Mass.
Const. amend. art. 114
REQUIREMENTS
A program shall assure that students with limited mobility have access,
free from barriers to their mobility, to those areas of the buildings and
grounds to which such access is necessary for the implementation of the
IEPs for such students. All programs receiving federal funds shall meet
the requirements of Section 504 of the Rehabilitation Act of 1973.
A program which enrolls students requiring wheelchairs shall have at
least one entrance without steps and wide enough for a wheelchair, for
each building utilized in carrying out the IEPs for such students.
If any part of the program is not accessible to students with limited
physical mobility, a plan and timetable shall be provided that
describes how the program will make all programs and appropriate
buildings accessible.
SOURCE OF INFORMATION
Documentation:
 Narrative descriptions and floor plans indicating
accessibility status
 Any program which is not accessible must
submit the following documentation:
o A plan that details steps to be taken to comply
with Section 504 of the Rehabilitation Act of
1973;
o The name of the person responsible for
implementation of the plan; and
o A timetable for completion of the above plan
including periodic written progress reporting
to the Department of Elementary and
Secondary Education.
Observation:
o Observations of physical facilities to ensure
students with limited mobility have access,
free from barriers to their mobility, to those
areas of the school buildings and grounds to
which such access is necessary for the
implementation of the IEP’s for such students
Interviews:
 Board of Directors
 Executive Director
 Education Director
 Director of Operations
 Teachers
 Parents
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 34 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
13.7 Library/Resource
Room
18.04(6)(b)
REQUIREMENTS
In addition to the regular instructional area, the program shall have a
separate library or resource room that contains a variety of materials
appropriate to the age and abilities of the students enrolled, and is
available to all enrolled students.
SOURCE OF INFORMATION
Documentation:
 Description of library or resource area including
types of materials available for student use; and
 Statement addresses when and how often
students access the library
Observation:
 Observation to ensure the program has a
separate library or resource room that contains a
variety of materials and is available to all
enrolled students
Interviews:
 All Staff
AREA 14: REQUIREMENTS FOR DAILY CARE
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
14.2 Food and
Nutrition
603 CMR 18.03(7);
G.L. c. 69, § 1(C);
Chapter 346 of the
Acts of 1986; See also
memo dated April 26,
2013 posted at
http://www.doe.mass.
edu/news/news.aspx?i
d=7422;
REQUIREMENTS
Sending school districts and approved private and public special
education school programs must collaborate to make breakfast and lunch
available to publicly-funded students with disabilities if they would have
had access to such meals in their sending school district. Also, if a
student is eligible for free or reduced price meal benefits, that benefit
must be available to the student while the student attends the approved
private or public special education school program. School districts are
required to communicate with such out-of-district programs whenever a
student is determined to be eligible for a free or reduced price breakfast
and/or lunch and/or whenever a student’s eligibility status for school
meals changes. Approved private and public special education school
SOURCE OF INFORMATION
Documentation:
 Copy of written plan describing how the
required communication between the program
and the sending school district(s) occurs
addressing lunch, and breakfast where
applicable
 Name and Title of person(s) responsible for
oversight of communication addressing lunch,
and if applicable, also breakfast
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 35 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
Section 504 of the
Rehabilitation Act of
1973
REQUIREMENTS
programs should review the availability of meals to students who are
publicly funded and sending school districts should do likewise with
respect to students placed in such programs by the sending school
district.
SOURCE OF INFORMATION
 Evidence, in the form of letters and/or emails, of
the communication between the program and the
sending school district(s) about lunch, and if
applicable, also breakfast
Interviews:
Executive Director
Education Director
AREA 15: PARENT AND STUDENT INVOLEMENT
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
15.1 Parental
Involvement and
Parents’ Advisory
Group
18.05(4)(a)
REQUIREMENTS
The program shall have a written plan for involving parents and shall
have a Parents’ Advisory Group that shall advise the program on matters
that pertain to the education, health and safety of the students in the
program.
The program shall designate a staff person to support the Parents’
Advisory Group.
SOURCE OF INFORMATION
Documentation:
 Parent involvement plan in manual describing
outreach to parents and steps to be taken to seek
parental input on matters pertaining to student
health, education and safety
 Position title and job description of staff person
assigned to work with Parents’ Advisory Group
 Copies of schedules and agendas for Parent
Advisory Group meetings
Interviews:
 Board of Directors
 All Staff
 Parents
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 36 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
15.3 Information to be
Translated into
Languages Other Than
English
REQUIREMENTS
When students have parents or guardians with limited English language
skills, the program ensures that important school information is sent to
them in a timely manner and provided to them in a language that they
understand, either through written translations of documents or through
oral interpreters.
Title VI; EEOA: 20
U.S.C. 1703(f);
M.G.L. c. 76, § 5; 603
CMR 26.02(2)
SOURCE OF INFORMATION
Documentation:
 Copies of important program announcements
and notices published in languages other than
English (must include program’s Behavior
Management Policy and Procedures, if
applicable)
 Description of how program will respond
promptly to parent/guardian requests to have
other important school information translated on
demand, either orally or in writing
Student Record Reviews:
 Copies of written translations of documents
(consent letters, progress reports, incident
reports), as applicable
Interviews:







15.5 Parent Consent
and Required
Notification
18.05(5)(c); 18.05(8);
18.05(9)(f)(1); 18.05
The program shall develop and implement policy and procedures to
work with school districts to obtain the following consents:
 Annual:
o Emergency medical treatment
o Medication Administration (when applicable)
Executive Director
Program Director
Education Director
Residential Director
Teachers
Parents
Public School Contact Person
Documentation:
 Copy of written policy procedures for working
with school districts to obtain parent consents
 Sample of all consent and notification forms
used by the school
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 37 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
(9)(j); M.G.L. c. 71, §
32A
REQUIREMENTS
 When applicable:
o Research
o Experimentation
o Fundraising
o Publicity and
o Observation
 The program’s policy and procedures shall include, when applicable,
notification pursuant to Parental Notification Law M.G.L. c. 71, §
32A concerning curriculum that primarily involves human sexual
education or human sexuality issues.
15.8 Registering
Complaints and
Grievances –Parents,
Students and
Employees
 The private special education program shall develop, implement and
make available to parents and, when applicable, students a set of
written procedures that may be used to register complaints regarding
the student’s education and care at the school that includes specific
timelines and the appeals process.
18.05(1)(b)(16);
Title IX: 20 U.S.C.
1681; 34 CFR 106.8;
Section 504: 29
U.S.C. 794; 34 CFR
104.7; Title II: 42
U.S.C. 12132; 28 CFR
35.107; 603 CMR
26.00 as amended by
Chapter 199 of the
Acts of 2011
 The private special education program must also adopt and publish
grievance procedures for students providing for prompt and
equitable resolution of complaints alleging discrimination based on
legally protected categories (race, color, sex, gender identity,
religion, national origin, sexual orientation, disability or
homelessness) that includes specific timelines and the appeals
process.
 The private special education program must also adopt and publish
grievance procedures for employees providing for prompt and
equitable resolution of complaints alleging discrimination based on
legally protected categories (race, color, sex, gender identity,
religion, national origin, sexual orientation, disability or
homelessness) that includes specific timelines and the appeals
process.
SOURCE OF INFORMATION
Student Record Reviews:
All required consents and notification
Interviews:







Executive Director
Program Director
Education Director
Residential Director
Clinical Director
Public School Contact person
Parents
Documentation:
 Name, position and title of person(s) responsible
for investigating and resolving complaints
regarding students’ education and care
 Copy of complaint procedures from manual
 Name, position and title of person(s) responsible
for investigating and resolving discrimination
complaints made on behalf of employees and
students
 Copy of grievance policy and procedure for
students
 Copy of grievance policy and procedure for
employees
 Copy of written procedures that are made
available to students, parents and/or employees
for the purpose of registering such complaints
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 38 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS
SOURCE OF INFORMATION
Staff Record Reviews:
 Copies of employee grievances and resolutions,
as applicable.
Student Record Reviews:
 Copies of student complaints and grievances and
resolutions as applicable
Interviews:
 All Staff
 Parents
AREA 16: HEALTH AND MEDICAL SERVICES
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
16.2 Physician
Consultation
18.05(9)(a)
M.G.L c. 71, §§ 53,
53A, and 53B
REQUIREMENTS
The program shall have a licensed physician available for consultation.
NOTE: School Physician means a physician appointed by a School
Committee or Board of Health in accordance with M.G.L c. 71, §§ 53,
53A, and 53B or, in the case of a private program, by the Board of
Trustees.
SOURCE OF INFORMATION
Documentation:
 Name and address of licensed physician
employed/contracted by the program
 Description of services provided to the program
Interviews:




Executive Director
Program Director
Nurses
Physician
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 39 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
16.3 Nursing
18.05(9)(b)
M.G.L c. 112
M.G.L. c. 71, §§ 53,
53A, and 53B
16.4 Emergency First
Aid and Medical
Treatment
18.05(9)(e, f)
REQUIREMENTS
The program shall have a registered nurse available depending upon the
health care needs of the program’s population.
SOURCE OF INFORMATION
Documentation:
 Name(s) of school nurse R.N.
 Shift schedule
 Explanation of how nurse’s availability is
sufficient for needs of the student population
NOTE: School Nurse means a nurse practicing in a school setting, who
is:
(1) a graduate of an approved school for professional nursing;
(2) currently licensed as a Registered Nurse pursuant to M.G.L c. Interviews:
 Executive Director
112; and
 Program Director
(3) appointed by a School Committee or a Board of Health in
 Residential Director
accordance with M.G.L. c. 71, §§ 53, 53A, and 53B or, in the
 Education Director
case of a private school, by the Board of Trustees.
 Nurses
 Consulting Physician
The program shall have develop and implement policies and procedures Documentation:
for emergency first aid and medical treatment, including:
 Copy of written policies and procedures for
 No emergency first aid or medical treatment is administered to a
emergency first aid and treatment from health
student without written authorization from a parent. Such
care manual
authorization shall be renewed annually;
 Secure storage of adequate first aid supplies, including but not
Interviews:
limited to bandages, body substance isolation gloves, gauze,
 All Staff
adhesive tape, and cleaning solutions;
 Easy access to first aid supplies in major activities areas;
 Procedures to be followed in the case of illness or emergency,
including methods of transportation and notification of parents;
 A procedure for informing parents or the Department of Children
and Families if appropriate of any medical care administered to their
child other than basic first aid. (For students in the Department of
Children and Families care or custody, an Educational Surrogate
Parent shall not have authority to consent to routine or other medical
care. For such students, consent shall be obtained consistent with the
applicable Department of Children and Families requirements); and
 Procedures to be followed in the case of illness or emergency if
parents cannot be reached.
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
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CRITERION
NUMBER, TOPIC
REQUIREMENTS
AND LEGAL
STANDARD
16.5 Administration of The program shall develop and implement written policy and procedures
Medication
regarding the administration of medication including, but not limited to,
the following:
18.05(9)(f)(8)
 No medication is administered to a student without written
authorization from a parent. Such authorization shall be renewed
annually.
 No prescription medication shall be administered to a student
without the written order of the physician prescribing the medication
to that student.
 The program maintains written policies and procedures regarding
prescription and administration of medication including
authorization, prepackaging and staff training.
 Any change of medication or dosage must be authorized by a new
order from a physician.
 A written record shall be maintained of the prescription of
medication to students. A written record shall also be maintained of
the administration of prescribed medication to students. Significant
side effects of medications shall also be recorded.
 Only trained staff may administer medication.
 All medicine shall be kept in a locked, secure cabinet and labeled
with the student's name, the name of the drug and the directions for
its administration.
 The program shall dispose of or return to the parents any unused
medication.
 Medications must be delivered to the school by a responsible adult
in a container labeled by the physician or pharmacist.
 Provisions must be made for refrigeration of medications, when
necessary.
 The program shall have a written policy regarding the amount of
medication to be kept on the premises at any one time for each
student receiving medication.
 A review of medications administered to a student shall be
incorporated into all case reviews conducted at the school with staff
regarding the student.
SOURCE OF INFORMATION
Documentation:
 Copy of written policy and procedures for
administration of medication
Interviews:






Executive Director
Program Director
Education Director
Residential Director
Nurse
Designated Medication Trained Staff
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 41 of 63
CRITERION
NUMBER, TOPIC
REQUIREMENTS
AND LEGAL
STANDARD
16.6 Administration of The program shall develop and implement written policy and procedures
Antipsychotic
for the administration of antipsychotic medication. The policy shall
Medication
include that the program shall not administer or arrange for the
administration of antipsychotic medication (drugs used in treating
18.05(9)(f)(9)
psychoses and alleviating psychotic states) except under the following
circumstances:
 Antipsychotic medication shall be prescribed by a licensed
physician for the diagnosis, treatment and care of the child and only
after review of the student's medical record and actual observation
of the student.
 The prescribing physician shall submit a written report to the school
detailing the necessity for the medication, staff monitoring
requirements, potential side effects that may or may not require
medical attention and the next scheduled clinical meeting or series
of meetings with the student.
 No antipsychotic prescription shall be administered for a period
longer than is medically necessary and students on antipsychotic
medication must be carefully monitored by a physician.
 Staff providing care to a student receiving antipsychotic medication
shall be instructed regarding the nature of the medication, potential
side effects that may or may not require medical attention and
required monitoring or special precautions, if any.
 Except in an emergency, as defined in 18.05 (9)(g), the school shall
neither administer nor arrange for the prescription and
administration of antipsychotic medication unless informed written
consent is obtained. If a student is in the custody of his/her
parent(s), parental consent in writing is required. Parental consent
may be revoked at any time unless subject to any court order. If the
parent does not consent or is not available to give consent, the
referral source shall be notified and judicial approval shall be
sought. If a student is in the custody of a person other than the
parent, a placement agency or an out-of-state public or private
agency, the referral source shall be notified and judicial approval
shall be sought.
SOURCE OF INFORMATION
Documentation:
 Copy of written policy and procedures for
administration of antipsychotic medication
Interviews:






Executive Director
Program Director
Education Director
Residential Director
Nurse
Designated Medication Trained Staff
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 42 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
16.7 Preventive
Health Care
18.05(9)(g)(1); 105
CMR 200.100(B)(1);
105 CMR 200.400(B);
105 CMR 200.400(C);
G.L. c. 71, § 57; and
G.L. c. 111, § 111.
REQUIREMENTS
 In an emergency situation, antipsychotic medication may be
administered for treatment purposes without parental consent or
prior judicial approval if an unforeseen combination of
circumstances or the resulting state calls for immediate action and
there is no less intrusive alternative to the medication. The treating
physician must determine that medication is necessary to prevent the
immediate substantial and irreversible deterioration of a serious
mental illness. If the treating physician determines that medication
should continue, informed consent or judicial approval must be
obtained as required by 18.05(9)(e).
 The program shall inform a student twelve years of age and older,
consistent with the student's capacity to understand, about the
treatment, risks and potential side effects of such medication. The
program shall specify and follow procedures if the student refuses to
consent to administration of the medication.
The program shall describe in writing a plan for the preventive health
care of students:
 603 CMR 18.05(9)(g)(1) Dental
The program, in cooperation with the student's parents and/or human
service agency, which is responsible for payment, shall make
provision for each student to receive an annual comprehensive dental
examination.
 105 CMR 200.100(B)(1) Physical
The program shall ensure that every student be separately and
carefully examined by a duly licensed physician, nurse practitioner
or physician assistant upon admission (within one year prior to
entrance to program or within 30 days after program entry) and
every 3-4 years afterwards. The program shall require a written
report from the physician(s) of the results of the examination and any
recommendation and/or modification of the student's activity.
 105 CMR 200.400(B) Vision
The program shall, in cooperation with the student's public school,
develop a plan to ensure that vision screenings are conducted. The
SOURCE OF INFORMATION
Documentation:
 Copy of written plan for preventive health
care from health care manual
Student Record Reviews:
 Evidence of preventive health care
screenings, medical and dental
examinations and immunization and/or
dated documentation of calls/emails/letters
to parents/guardians requesting such
documentation
Interviews:
 Executive Director
 Program Director
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 43 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS





vision of each student in the program is to be screened in the year of
program entry; annually through grade 5 (or by age 11 in ungraded
classrooms); once in grades 6 through 8 (or ages 12 through 14 in
ungraded classrooms); and once in grades 9 through 12 (or ages 15
through 18 in ungraded classrooms).
105 CMR 200.400(C) Hearing
The program shall, in cooperation with the student's public school,
develop a plan to ensure that hearing screenings are conducted. The
hearing of each student in the program is to be screened in the year
of program entry; annually through grade 3 (or by age 9 in the case
of ungraded classrooms); once in grades 6 through 8 (ages 12
through 14 in the case of ungraded classrooms); and once in grades 9
through 12 (ages 15 through 18 in the case of ungraded classrooms).
G.L. c.71, § 57 Posture
The program shall, in cooperation with the student's public school,
develop a plan to ensure that postural screenings are conducted.
Tests ascertaining postural defects shall be administered at least once
annually in grades 5 through 9.
The program shall have a policy and procedure for assuring that a
student or staff member who has a reported communicable disease
shall be authorized by a physician to continue to be present within
the school and for notifying all parents and referring agencies of the
introduction of a reported communicable disease into the program.
The local board of health must be notified in accordance with
M.G.L. c. 111, § 111.
The program shall provide a locked, secure cabinet to keep all toxic
substances, medications, sharp objects and matches out of the reach
of students. Medications and medical supplies should not be locked
in the same cabinet as other toxic substances. Toxic substances must
be labeled with contents and antidote. The phone number for the
nearest poison center must be posted clearly.
Where appropriate, the program shall provide or arrange for the
provision of family planning information, subject to any applicable
state or federal legislation.
SOURCE OF INFORMATION


Nurses
Parents
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 44 of 63
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
REQUIREMENTS

SOURCE OF INFORMATION
The program shall require that all students have necessary
immunizations as required by the Department of Public Health.
NOTE: A new student must have a documented physical within one
year prior to their entrance to the program or the program must
coordinate with the parents/guardians for the student to obtain a physical
examination within 30 days of admission.
16.11 Student
Allergies
18.05(9)(h)
The program shall develop and implement written policy and procedures
for protecting a student from exposure to foods, chemicals, or other
materials to which they are allergic, as stated by their physician/medical
assessment.
Documentation:
 Copy of written student allergies policy and
procedures
Student Record Reviews:
 Notations of all individual student allergies and
plans for protection, as applicable
Interviews:
 All Staff
16.12 No Smoking
Policy
M.G.L. c. 71, § 37H
The program shall develop and implement a written policy that prohibits
the use of any tobacco products within the program buildings, the
program facilities or on the program grounds or on buses by any
individual, including school staff.
Documentation:
 Copy of written no smoking policy
Interviews:
 All Staff
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AREA 18: STUDENT RECORDS
CRITERION
REQUIREMENTS
NUMBER, TOPIC
AND LEGAL
STANDARD
18.1 Confidentiality of Programs shall keep current and complete files for each publicly funded
Student Records
enrolled Massachusetts student and shall manage such files consistent
with the Massachusetts Student Record Regulations of 603 CMR 23.00
28.09(5)(a);
and M.G.L. c. 71, § 34H.
28.09(10); 23.07(1);
 The program shall make the individual records of enrolled
M.G.L. c. 71, § 34H
Massachusetts students available to the Department of
Elementary and Secondary Education upon request.
 Staff notes or reports regarding a student shall be legibly dated
and signed by persons making entries.
 A log of access shall be kept as part of each student’s record. If
 parts of the student record are separately located, a separate log
shall be kept with each part. The log shall indicate all persons
who have obtained access to the student record, stating:
o the name, position and signature of the person releasing the
information; the name, position and, if a third party, the
affiliation if any, of the person who is to receive the
information;
o the date of access;
o the parts of the record to which access was obtained; and
o the purpose of such access.
o the purpose of such access.
SOURCE OF INFORMATION
Documentation:
 Name of person(s) responsible for oversight and
maintenance of student records
 Copy of log of access form
Student Record Reviews:
 Log of access
Interviews:
 All Staff
NOTE: Unless student record information is to be deleted or
released, this log requirement shall not apply to authorized staff who
inspect the student record, administrative office staff and clerical
staff who add information to or obtain access to the student record
and the school nurses who inspect the student health record.
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AREA 19: ANTI-HAZING
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
19 Anti-Hazing
M.G.L. c. 269, §§ 17
through 19
REQUIREMENTS
 The principal/education director of each school program serving
secondary school age students issues a copy of M.G.L. c. 269 §§ 17
through 19, to every student enrolled full-time, and every student
group, student team, or student organization, including every
unaffiliated student group, student team, or student organization, and
a copy of the school program's anti-hazing disciplinary policy
approved by the program's Board of Director's.
 Each school program serving secondary school age students files, at
least annually, a report with the Department certifying
a) Its compliance with its responsibility to inform student groups,
teams, or organizations, and every full-time enrolled student, of the
provisions of M.G.L. c. 269 §§ 17 through 19;
b) Its adoption of a disciplinary policy with regard to the
organizers and participants of hazing; and
c) That the hazing policy has been included in the student
handbook or other means of communicating school program policies
to students.
SOURCE OF INFORMATION
Documentation:
 Report on file with Department on or before
October 1st
 Copies of student handbooks or disciplinary
code distributed to students
 Documentation of students’ receipt of a copy of
the school program's anti-hazing disciplinary
policy approved by the program's Board of
Director's
Interviews:
 All Staff
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AREA 20: BULLYING PREVENTION AND INTERVENTION
CRITERION
NUMBER, TOPIC
AND LEGAL
STANDARD
20 Bullying
Prevention and
Intervention
M.G.L. c. 71, § 37H,
as amended by
Chapter 92 of the Acts
of 2010; M.G.L. c. 71,
§§ 37O(d) as
amended, (e)(1)(2).
(IDEA-97)
REQUIREMENTS
1. All approved private special education school programs must update
school handbooks/admission materials to conform to their updated
amended Bullying Prevention and Intervention Plan (Plan). The
school handbook/admission materials (and local updated Plan) must
be consistent with the amendments to the Massachusetts antibullying
law, which became effective July 1, 2013. The amendments extend
protections to students who are bullied by a member of the school
staff. As defined in G.L. c. 71,37O(d), as amended, a member of the
school staff includes, but is not limited to, an “educator,
administrator, school nurse, cafeteria worker, custodian, bus driver,
athletic coach, advisor to an extracurricular activity or
paraprofessional.” The school handbook/admission materials must
make clear that a member of the school staff may be named the
“aggressor” or “perpetrator” in a bullying report.
2. Employee handbooks/policies and procedures must also contain
relevant sections of the amended Plan relating to the duties of
faculty and staff and relevant provisions addressing the bullying of
students by a school staff member.
3. Each year all approved private special education school programs
must give parents and guardians annual written notice of the studentrelated sections of the Plan.
4. Each year all approved private special education school programs
must provide all staff with annual written notice of the Plan.
5. All approved private special education school programs must
implement, for all school staff, professional development that
includes developmentally appropriate strategies to prevent bullying
incidents;
developmentally appropriate strategies for immediate,
effective
SOURCE OF INFORMATION
Documentation:

A description of the process the program
followed to amend and update its' student
handbooks/admissions materials, Bullying
Prevention and Intervention Plan, and anti-
bullying policies and policies pertaining to the
conduct of students and teachers to be consistent
with the Massachusetts anti-bullying law, which
became effective July 2013
 A description of how the Bullying Prevention
and Intervention Plan information was
distributed to parents, students and school
staff
 A description of any ongoing professional
development offered by the program for all
staff during the 2014-2015 School Year and
evidence of its implementation, to include
dates, format(s) used and agenda(s) if
appropriate
Interviews: All Staff, including:







Admissions Coordinators
Athletic Coaches
Bus Drivers
Cafeteria Workers/Cooks
Clinical Staff
Custodians/Maintenance Workers
Direct Care Workers I & II Day (Academic)
positions
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interventions to stop bullying incidents; information regarding the
complex interaction and power differential that can take place
between and among a perpetrator, victim and witnesses to the
bullying; research findings on bullying, including information about
specific categories of students who have been shown to be
particularly at risk for bullying in the school environment;
information on the
incidence and nature of cyber-bullying; and internet safety issues as
they relate to cyber-bullying.




Direct Care Workers I & II Residential positions
Nurses
Parents
Teachers
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MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION
APPROVED PRIVATE DAY AND RESIDENTIAL
MID-CYCLE REVIEW PROCEDURES
Mid-cycle Review Introduction
A Mid-cycle Review for each Approved Private School Program will be scheduled during the third year of the
program’s six year monitoring cycle. The Department’s 2015-2016 Approved Private School Programs
schedule of Mid-cycle Reviews is posted on the Department’s website at:
http://www.doe.mass.edu/pqa/review/psr/6yrcycle.html.
The Department conducts Mid-cycle Reviews, including onsite visits, to determine the effectiveness of
corrective action it has previously approved or ordered. In addition, the Department also monitors
compliance with selected state and federal requirements across all private school programs being reviewed for
a Mid-cycle.
All 2015-2016 Mid-cycle Reviews will include a review of all criteria listed in the Selected Mid-cycle
Review Criteria, as well as any areas of non-compliance that were identified during the program’s last
Program Review that required a written corrective action plan and are currently still part of our monitoring
standards; and any additional areas that were identified after the review in the form of complaints. The Midcycle Review Onsite Chairperson may also determine that additional areas must be reviewed and will inform
the program of any additional criteria.
EXIT MEETING AND PREPARATION OF
MID-CYCLE REVIEW REPORT
An informal Exit Meeting will be held with the Executive Director of the private school program and anyone
else of his/her choosing to summarize general impressions of the visit. The Department's Mid-cycle Review
Report is a public document that is to be made available by the program to its Board of Directors, parents and
the general public upon request. The Department of Elementary and Secondary Education also posts all
Private School Program Review and Mid-cycle Review Reports on its Internet Web site at
http://www.doe.mass.edu/pqa/review/psr/reports/followup.html
Upon issuance of the Mid-cycle Review Report, the program will receive an updated approval status. For
programs receiving a “Full Approval,” this approval will remain in effect for three (3) years expiring on
August 31st of the third year of approval. This approval will be contingent upon continued compliance with
all regulations contained within 603 CMR 28.00, “Special Education Regulations,” and
603 CMR 18.00, “Program And Safety Standards For Approved Public Or Private Day And Residential
Special Education School Programs,” as well as the Department’s approval of all required corrective
action plans and progress reports.
The Department of Elementary and Secondary Education may change this approval status at any point during
the three-year period if circumstances arise that warrant such a change. For Approved Private School
Programs receiving a “Provisional Approval” or “Probationary Approval,” the Department of Elementary and
Secondary Education will clearly indicate the reasons for the reduced approval, along with timelines for
compliance and an expiration date of the approval status. The Department will review all required progress
reports related to the Mid-cycle Review Report findings and issue written determinations regarding approval
or disapproval of these.
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NOTE: For programs undergoing Program Reconstruction, Special Circumstances or Extraordinary Relief,
please note that even if the program has substantially met all of the requirements for a Full Approval, the
program will remain on Provisional Approval until the completion of the Program Reconstruction, Special
Circumstances or Extraordinary Relief process.
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Selected Mid-cycle Review Criteria
School Year 2014-2015
CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
2.2 Approvals, Licenses,
Certificates of Inspection
18.04(1); 28.09(2)(b)(5);
28.09(5) (b); 28.09(6) (b, c)
REQUIREMENTS
The program has current licenses, approvals, and certificates of inspection by state
and local agencies.






2.3 EEC Licensure
102 CMR 3.00
(Residential Programs
only)
SOURCE OF INFORMATION
Documentation:
 Provide current copies of licenses,
approvals, and certificates of
inspection
Safety Inspection. The program shall have an appropriate certificate of inspection
from the Department of Public Safety or the local building inspector for each
building to which students have access;
Observation:
Fire Inspection. The program shall obtain a written report of an annual fire
 Posted Certificates
inspection from the local fire department;
Lead paint inspection (if facility was built prior to 1978). All buildings,
residential or otherwise, utilized by children younger than six or with a mental age
younger than six shall be free of lead paint;
Local Board of Health permit if providing food services;
Asbestos inspection or date when building was constructed and statement from
appropriate authority that building is asbestos-free (if asbestos is present, then a
containment plan is necessary); and
Statement regarding the non-existence of PCBs, or, if PCBs are present, then a
containment plan.
The residential program has a current, full license from the Department of Early
Education and Care (EEC) (per 102 CMR 3.00). Approval by EEC to operate a group
care facility or a day care center (if applicable).
Documentation:
 Provide copy of EEC license
Interviews:
 Executive Director/Program Director
 Residential Director
 EEC Licensing Specialist
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CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
6.1 Daily Instructional
Hours
603 CMR 27.04
REQUIREMENTS
The program ensures that each student is scheduled to receive an average minimum of
the following instructional hours unless otherwise approved by ESE or a student’s IEP
provides otherwise:
 Elementary – A total of:
10 month program – 900 hours
11 month program – 990 hours
12 month program – 1080 hours
 Secondary – A total of:
10 month program – 990 hours
11 month program –1089 hours
12 month program – 1188 hours
The program ensures that, unless a student’s IEP provides otherwise, each elementary
school student is scheduled for at least 900 hours of structured learning time a year
and each secondary school student is scheduled for at least 990 hours of structured
learning time a year (including physical education for all students, required by M.G.L.
c. 71, § 3), within the required school year schedule. Where the private special
education program operates separate middle schools, at the beginning of the school
year it designates each one as either elementary or secondary.
NOTE: The program ensures that its structured learning time is time during which
students are engaged in regularly scheduled instruction, learning or assessments
within the curriculum of core subjects and other subjects as defined in 603 CMR
27.02. The program’s structured learning time may include directed study (activities
directly related to a program of studies, with a teacher available to assist students);
independent study (a rigorous, individually designed program under the direction of a
teacher, assigned a grade and credit); technology-assisted learning; presentations by
persons other than teachers; school-to-work programs; and statewide student
performance assessments.
SOURCE OF INFORMATION
Documentation:
Learning Time Worksheet
 Block schedule that includes:
o Beginning and ending time for
each instructional block;
o Subject area for each block;
o All non-instructional time (e.g.
lunch, recess, transitions
between classes, etc.,.); and
o If non-instructional time
activities are counted as
instructional hours, they must
be specified in student’s IEPs
 Calculation of the total number of
instructional hours per year with
documentation of how total was
determined
Interviews:




Education Director
Teachers
Related Service Providers
Direct Care Staff
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CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
6.4 School Days Per Year
603 CMR 27.05(2);
28.09(9)(a)
REQUIREMENTS
All programs are run for the following minimum number of days (exclusive of
weekends, holidays, vacations):
 10 month program - 180 days
 11 month program – 198 days
 12 month program – 216 days
Before the beginning of each school year, the program sets a school year schedule for
each program. This schedule must include at least five additional school days to
account for unforeseen circumstances (i.e., snowstorms).
NOTE: All programs must schedule the number of school days per ESE’s application
approval plus five additional days for unforeseen circumstances.
SOURCE OF INFORMATION
Documentation:
 Copy of school calendar for school
year clearly indicating number of
scheduled days
o The last day of school must be
indicated
o Five additional school days to
account for unforeseen
circumstances must be indicated
o The last day of school must be
indicated for high school seniors
Interviews:
 All Staff
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CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
8.5 Current IEP & Student
Roster
28.09(5)(a)
REQUIREMENTS
The program has on file a current IEP for each enrolled Massachusetts student that
has been issued by the responsible public school district and consented to and dated
by the student’s parent(s) (or student, when applicable).
SOURCE OF INFORMATION
Documentation:
Student Roster Form
 A roster of publicly funded
Massachusetts students currently
enrolled in the program containing
the following information:
o Each student’s initials (not
name);
o The school district responsible
for preparing the student’s IEP;
o The agency(ies) supporting any
part of the student’s tuition;
o The portion of tuition supported
by such agency(ies);
o The implementation date of the
current IEP;
o The date of expiration for the
student’s current IEP;
o The date of parental signature;
o The name of the school district
contact person for each student;
and
o For each unsigned IEP,
evidence/documentation of
efforts and/or steps taken for the
public school district to obtain
signed IEPs
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CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
REQUIREMENTS
SOURCE OF INFORMATION
Student Record Reviews:

Current IEPs of students
Interviews:
 Education Director
 Teachers
 Parents
 Public School Contact Person
11.3 Educational
Administrator
Qualifications
28.09(5)(a); 28.09(7)(a);
603 CMR 44.00
At least one staff member shall be designated as the educational administrator for the
Documentation:
program. Such person shall be assigned to supervise the provision of special education  Name of educational administrator(s)
services in the program and to ensure that the services specified in each student’s IEP
and
are delivered. The educational administrator shall either possess licensure as a special
 Copy of licensure as a special
education administrator or possess all of the following:
education administrator
 License as a special educator;
 A minimum of a master's degree in special education or a related field; and
or ALL of the following:
 A minimum of one year of administrative experience.
 Copy of license as a special educator
or copy of ELAR activity sheet; and,
The educational administrator shall be re-licensed pursuant to the requirements of 603
 Evidence of Master’s Degree in
CMR 44.00.
special education or a related field;
and
The educational administrator shall obtain supervisory approval of his/her
 Evidence of a minimum of one year
Professional Development Plan per 603 CMR 44.0, if applicable.
of administrative experience
(acceptable documentation includes a
current resume)
Staff Record Reviews:
 Professional Development Plan
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CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
11.4 Teachers
(Special Education
Teachers and General
Education Teachers)
18.05(11)(f); 28.09 (5)(a);
28.09(7)(b,c); 34 CFR
300.321
REQUIREMENTS
The program must ensure that all teaching staff have teaching licenses appropriate to
meet the needs of the population being served pursuant to the requirements of 603
CMR 7.00 and, additionally, must adhere to the following requirements:
 All teaching staff shall be re-licensed pursuant to the requirements of 603 CMR
44.00 including obtaining supervisor approval of Professional Development Plans
pursuant to 603 CMR 44.04, if applicable.
 To the extent that teaching staff is providing special education services, such
services shall be provided, designed, or supervised by a special educator.
 A program’s teacher who has knowledge about the education and learning
progress of the student must be in attendance at the IEP meeting for the student.
At least half of the teaching staff shall be licensed in special education areas
appropriate to the population served at the program; other teaching staff may be
licensed in other educational areas, in order to provide for content expertise in the
general curriculum. The Department of Elementary and Secondary Education may
require a higher proportion of licensed special educators if, in the opinion of the
Department, the population requires more specialized services.
The number of special education teachers and the number of the general education
teachers must correspond with the most recent Department-approved budget.
SOURCE OF INFORMATION
Documentation:
Teacher Roster Form
 Provide a statement regarding the
most recent Department-approved
number of special education teachers
and general education teachers
 Current teaching staff roster that
includes all UFR 115’s special
education teachers and UFR 116’s
general education teachers in the
program that contains the following
information:
o UFR#;
o Name;
o Position title within the program;
o Grade level(s) taught;
o Subject(s) taught;
o Massachusetts teaching license
title, type, grade level, number
and expiration date; and
o Copy of license or most current
ELAR activity sheet.
Interviews:





Board of Directors
Executive Director
Program Director
Education Director
Teachers
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CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
11.5 Related Services Staff
28.09(7)(d)
REQUIREMENTS
SOURCE OF INFORMATION
All staff providing or supervising the provision of related services (including
consultants) shall be appropriately certified, licensed or registered in their professional
areas.
Documentation:
Related Services Provider Form
 A current roster for all related service
providers that includes each
provider’s
o UFR #;
o Name;
o Position title within program; and
o License number and/or
Massachusetts State Board of
Registration number
 Copy of License and/or
Massachusetts State Board of
Registration
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CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
REQUIREMENTS
SOURCE OF INFORMATION
Interviews:






11.6 Master Staff Roster
28.09(7)
The program maintains a master list of ALL staff for every position within the
program. The staff positions shall correspond to the last Department-approved
Program Budget. This list must include job titles along with their corresponding UFR
title numbers and full-time equivalents (FTE’s). This list may include, but is not
limited to:
 Administrators
 Special education teachers
 General education teachers
 Related service providers
 Registered Nurses
 Direct care workers
 Direct care supervisors
 Clerical and maintenance staff
 Psychologists
 Social workers
 Food service staff
 Consultants
Any changes/discrepancies from the last Department-approved Program Budget
(through Initial Application, Extraordinary Relief, Special Circumstances, Program
Reconstruction) must be described on the Master Staff Roster template (that can be
found in the Appendix I).
Executive Director
Education Director
Clinical Director
Clinicians
Nurse
Related Service Providers
Documentation:
Master Staff Roster Form
 Copy of the last Departmentapproved Program Budget
 A current master staff roster that
includes for each staff person
o
Corresponding UFR#s
o
UFR tittles
o
Full time equivalents
(FTEs)
o
Position title
o
First and Last name
o
Vacancies indicated
o Justification for any
o discrepancies from last
approved program budget
Interviews:




Board of Directors
Executive Director
Program Director
Director of Human Resources/Staff
Administration
 Director of Operations
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CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
11.12 Equal Access
Mass. Const. amend. Art.
114; M.G.L. c. 76, § 5; 603
CMR 26.00 as amended by
Chapter 199 of the Acts of
2011; Title VI: 42 U.S.C.
2000d; 34 CFR 100.3(a),
(b); Title IX: 20 U.S.C.
1681; 34 CFR 106; Section
504: 29 U.S.C. 794; 34
CFR 104; Title II: 42
U.S.C.12132; 28 CFR
35.130; NCLB: Title X,
Part C, § 721.
REQUIREMENTS
The program provides all students with equal access to services, facilities, activities
and benefits regardless of race, color, sex, gender identity, religion, national origin,
sexual orientation, disability or homelessness.
1. The program provides equal opportunity for all students to participate in intramural
and interscholastic sports; and
2. Extracurricular activities or clubs sponsored by the program do not exclude
students on the basis of race, color, sex, gender identity, religion, national origin,
sexual orientation, disability or homelessness.
SOURCE OF INFORMATION
Documentation:

Equal Access policy

List of intramural and
interscholastic sports offerings,
extracurricular activities and clubs
sponsored by the program as well as
requirements for participation in
each of these activities

List and location of any separate
facilities, activities or services
provided on the basis of any other
protected category (race, color, sex,
gender identity, religion, national
origin, sexual orientation, disability
or homelessness), with narrative
explaining reason for separation and
confirming comparability
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CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
14.2 Food and Nutrition
603 CMR 18.03(7); G.L. c.
69, § 1(C); Chapter 346 of
the Acts of 1986; See also
memo dated April 26, 2013
posted at
http://www.doe.mass.edu/n
ews/news.aspx?id=7422
(IDEA-97)
Section 504 of the
Rehabilitation Act of 1973
REQUIREMENTS
Sending school districts and approved private and public special education school
programs must collaborate to make breakfast and lunch available to publicly-funded
students with disabilities if they would have had access to such meals in their sending
school district. Also, if a student is eligible for free or reduced price meal benefits,
that benefit must be available to the student while the student attends the approved
private or public special education school program. School districts are required to
communicate with such out-of-district programs whenever a student is determined to
be eligible for a free or reduced price breakfast and/or lunch and/or whenever a
student’s eligibility status for school meals changes. Approved private and public
special education school programs should review the availability of meals to students
who are publicly funded and sending school districts should do likewise with respect
to students placed in such programs by the sending school district.
SOURCE OF INFORMATION
Documentation:

Copy of written plan describing
how the required communication
between the program and the
sending school district(s) occurs
addressing lunch, and breakfast
where applicable

Name and Title of person(s)
responsible for oversight of
communication addressing lunch,
and if applicable, also breakfast

Evidence, in the form of letters
and/or emails, of the
communication between the
program and the sending school
district(s) about lunch, and if
applicable, also breakfast
Interviews:
Executive Director
Education Director
19 Anti-Hazing
M.G.L. c. 269, §§ 17
through 19
 The principal/education director of each school program serving secondary school
age students issues a copy of M.G.L. c. 269 §§ 17 through 19, to every student
enrolled full-time, and every student group, student team, or student organization,
including every unaffiliated student group, student team, or student organization,
and a copy of the school program's anti-hazing disciplinary policy approved by the
program's Board of Director's.
Documentation:
 Report on file with Department on or
before October 1st
 Copies of student handbooks or
disciplinary code distributed to
students
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CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
20 Bullying Prevention and
Intervention
M.G.L. c. 71, § 37H, as
amended by Chapter 92 of
the Acts of 2010; M.G.L. c.
71, §§ 37O(d) as amended,
(e)(1)(2).
(IDEA-97)
REQUIREMENTS
SOURCE OF INFORMATION
 Each school program serving secondary school age students files, at least annually,
a report with the Department certifying
a) Its compliance with its responsibility to inform student groups, teams, or
organizations, and every full-time enrolled student, of the provisions of
M.G.L. c.269 §§ 17 through 19;
b) Its adoption of a disciplinary policy with regard to the organizers and
participants of hazing; and
c) That the hazing policy has been included in the student handbook or other
means of communicating school program policies to students.
 Documentation of students’ receipt
of a copy of the school program's
anti-hazing disciplinary policy
approved by the program's Board of
Director's
1. All approved private special education school programs must update school
handbooks/admission materials to conform to their updated amended Bullying
Prevention and Intervention Plan (Plan). The school handbook/admission
materials (and local updated Plan) must be consistent with the amendments to the
Massachusetts anti-bullying law, which became effective July 1, 2013. The
amendments extend protections to students who are bullied by a member of the
school staff. As defined in G.L. c. 71,37O(d), as amended, a member of the
school staff includes, but is not limited to, an “educator, administrator, school
nurse, cafeteria worker, custodian, bus driver, athletic coach, advisor to an
extracurricular activity or paraprofessional.” The school handbook/admission
materials must make clear that a member of the school staff may be named the
“aggressor” or “perpetrator” in a bullying report.
Documentation:
2. Employee handbooks/policies and procedures must also contain relevant sections of
the amended Plan relating to the duties of faculty and staff and relevant provisions
addressing the bullying of students by a school staff member.
Interviews:
 All Staff

A description of the process the
program followed to amend and
update its' student
handbooks/admissions materials,
Bullying Prevention and
Intervention Plan, and antibullying policies and policies
pertaining to the conduct of
students and teachers to be
consistent with the Massachusetts
anti-bullying law, which became
effective July 2013

A description of how the Bullying
Prevention and Intervention Plan
information was distributed to
parents, students and school staff

A description of any ongoing
professional development offered
by the program for all staff during
3. Each year all approved private special education school programs must give parents
and guardians annual written notice of the student-related sections of the Plan.
4. Each year all approved private special education school programs must provide all
staff with annual written notice of the Plan.
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 62 of 63
CRITERION NUMBER,
TOPIC AND LEGAL
STANDARD
REQUIREMENTS
5. All approved private special education school programs must implement, for all
school staff, professional development that includes developmentally appropriate
strategies to prevent bullying incidents; developmentally appropriate strategies for
immediate, effective interventions to stop bullying incidents; information
regarding the complex interaction and power differential that can take place
between and among a perpetrator, victim and witnesses to the bullying; research
findings on bullying, including information about specific categories of students
who have been shown to be particularly at risk for bullying in the school
environment; information on the incidence and nature of cyber-bullying; and
internet safety issues as they relate to cyber-bullying.
SOURCE OF INFORMATION
the 2014-2015 School Year and
evidence of its implementation, to
include dates, format(s) used and
agenda(s) if appropriate
Interviews: All Staff, including:
 Admissions Coordinators
 Athletic Coaches
 Bus Drivers
 Cafeteria Workers/Cooks
 Clinical Staff
 Custodians/Maintenance Workers
 Direct Care Workers I & II Day
(Academic) positions
 Direct Care Workers I & II
Residential positions
 Nurses
 Parents
 Teachers
Approved Private School Education Program and Mid-cycle Review Procedures – 2015-2016
Page 63 of 63
Appendix I
Private School
Structured Learning Time Worksheet
Pursuant to Criteria:
PS 6.1 – Daily Instructional Hours
PS 6.1(a) – Physical Education Requirements
PS 6.4 – School Days Per Year; Release of High School Seniors
PS 6.1 Daily Instructional Hours and 6.4 School Days Per Year; Release of High School Seniors
PS 6.1(a) – Physical Education Requirements
Student Learning Time Worksheet
Purpose and Directions
PURPOSE:
The purpose of the Student Learning Time Regulations (603 CMR 27.00) is to ensure that every publicly-funded
school in Massachusetts provides sufficient structured learning time equitably for all students. The Department of
Elementary and Secondary Education (“Department”) requires each publicly-funded Massachusetts student attending
an approved private special education school program to be scheduled to receive the number of instructional hours
the program was approved by the Department to deliver unless otherwise indicated in a student’s IEP. During a
Program Review, as part of the Department’s efforts to ensure compliance with these regulations, the Department
reviews the structured learning time for every approved program an agency operates in order to verify that all
students are scheduled to receive the approved amount in accordance with monitoring standards PS 6.1 Daily
Instructional Hours and PS 6.4 School Days Per Year; Release of High School Seniors, as well as PS 6.1(a) Physical
Education Requirements. An agency is required to make any changes necessary to conform with the Board of
Elementary and Secondary Education’s regulations in this regard.
DIRECTIONS:
An agency must upload this document in order for the Department to determine if students are
scheduled to receive the number of instructional hours a program was approved by the
Department to provide. A separate worksheet should be used for each approved program where
an agency operates more than one program. If any program is not in full compliance with the
student learning time standards described under the program review criteria PS 6.1 and 6.4, or
physical education requirements under PS 6.1(a) pursuant to M.G.L. c.71, sec.3, it should prepare
a written plan to bring the effected program into full compliance and upload that plan under
“Additional Documents” after the agency’s self-assessment has been submitted.
AGENCY
STUDENT LEARNING TIME WORKSHEET
(Page 1 of 2)
Agency Name: _________________________________________________
Program Name(s): _________________________________________________
1. How many total days are scheduled for the school year including days set aside for professional development and weatherrelated days?
______days
2. How many days in the school year are ALL students scheduled to attend?
 Do not include kindergarten.
 Do not include orientation days unless all grades are in attendance.
 Do not subtract senior early release days.
______days
3. If the program operates any middle school programs, they are designated as:
(Check one)
_____Elementary (900 hours) OR_____Secondary (990 hours)
4. How many annual hours is the program scheduled for kindergarten students? (Label “NA” any type of program that does
not exist.)
_______Morning half-day programs
_______Afternoon half-day programs
_______Full-day programs
5. Are there any programs operated by the agency that are not in full compliance with program review criteria PS 6.1, 6.1(a)
and 6.4 (See http://www.doe.mass.edu/pqa/review/psr/instrument.pdf)?
Yes
No
(See Next Page)
AGENCY
STUDENT LEARNING TIME WORKSHEET
(Page 2 of 2)
Agency Name: _________________________________________________
Program Name(s): _________________________________________________
If “yes,” identify the programs(s) and, for each, the area(s) of noncompliance
___________________________________________________________________________________
___________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
and attach the agency’s plan to bring all programs into full compliance. At a minimum, this plan must include:
• A complete description of the corrective action activities the agency will implement
• Target completion dates
• Anticipated results
• Evidence of completion
• Person(s) responsible for implementation of activities
• The agency’s process for evaluating corrective action and ensuring ongoing compliance
______________________________________________________
(Signature and title of agency head completing this worksheet or designee)
_________________
(Date)
PROGRAM
STUDENT LEARNING TIME WORKSHEET
(Page 1 of 2)
Name of Program:__________________________________________________________
Level (Elementary, Middle, Secondary): __________________ Grades in Program:______________________
Check One:
This worksheet applies to all students within the program.
There is a separate copy of this worksheet attached for each instructional group whose schedule does
not conform to the program’s standard instructional schedule.
(On the separate copy, write the name of the group after the name of the program.)
1. Of the number of student days scheduled in the student year (the number of days the Department approved your program to
operate), how many are scheduled early release days or scheduled delayed opening days (e.g., day before holiday,
professional development, parent conferences)?
_______days
2. How many annual structured learning hours are students missing due to scheduled early release or scheduled delayed
opening?
_______hrs. _______mins.
3. The student day begins at _____A.M. and ends at _____P.M.; therefore the student day contains:
_______hrs. _______mins.
4. How much time is spent per day in homeroom, at breakfast and lunch, passing between classes, at recess, conducting health
screenings and preventative services and in non-directed study?
_______hrs. _______mins.
5. Subtract the amount of daily non-instructional time in number 4 from the total time indicated in number 3. This gives the
daily structured learning time per student.
_______hrs. _______mins.
6. How many days in a school year are ALL STUDENTS scheduled to attend?
 Do not include kindergarten.
 Do not include orientation days unless all students are required to attend.
 Do not subtract senior early release days.
_______days
7. Multiply the daily structured learning time indicated in number 5 by the number of student days in
number 6.
This equals:
_______hrs. _______mins.
8. From the total in number 7, subtract the time not scheduled because of early release or delayed opening indicated in number
2. This gives the amount of annual structured learning time.
_______hrs. _______mins.
(See Next Page)
PROGRAM
STUDENT LEARNING TIME WORKSHEET
(Page 2 of 2)
Name of Program:__________________________________________________________
9. List all grades (including kindergarten) in which physical education is taught as a required subject for all students in the
grade:
Grades: _________________________________________________________
10. (Only for programs that have grade 12)
What was the last day of attendance for seniors last year? _______________________________________
What was the date of graduation last year? _____________________________
What was the regular scheduled closing date for your school last year? ______________________________
(NOTE: No other group of students (grades 1-11) is eligible for release before the end of the school year.)
_________________________________________________
_______
(Signature and title of Education Admin., Education Dir. or Principal completing worksheet)
(Date)
Note: Where this school does not comply with PS 6.1, 6.1(a) or 6.4 an action plan to bring it into full
compliance can be attached to the agency’s Student Learning Time Worksheet Tool and uploaded into
Additional Documents in the WBMS.
(See http://www.doe.mass.edu/pqa/review/psr/instrument.pdf).
CRITERION 8.5
DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION STUDENT ROSTER
AGENCY NAME:________________________________________________________
PROGRAM NAME:______________________________________________________
NOTE: Include only publicly funded Massachusetts students currently enrolled in the program. Please list all students in alphabetical order by
last initial. For each IEP expiration date that has passed, provide a statement describing the efforts made by the program to obtain a current IEP. Include
specifics, such as who from the program provided the follow up; the date a call was made or a letter was issued; and the name of the person communicated
with from the sending school district
Student School district Name of the school district Agency(ies)
Portion of
Implementation Expiration date of Date of parental
initials
responsible for contact person
supporting
tuition
date of the most the most recently
signature on the most
preparing the
any part of
supported
recently issued
issued and
recently issued and
student’s IEP
the student’s by such
and consented to consented to IEP
consented to IEP
tuition
agency(ies) IEP
CRITERION 11.4
DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION TEACHER ROSTER
AGENCY NAME:________________________________________________________
PROGRAM NAME:______________________________________________________
NOTE: Only include staff identified as UFR #115 Special Education Teacher and UFR #116 Regular Education Teacher.
Reflect both the subject area and the grade level(s) actually covered by each teaching license.
Examples: Teacher of Students with Moderate Disabilities Grades PreK-8; Teacher of Students with Moderate Disabilities Grades 5-12; Teacher
of Students with Severe Disabilities All levels; Mathematics Grades 1-6; Mathematics Grades 5-8; Mathematics Grades 8-12.
UFR
#
NAME
Enter one name per line
POSITION TITLE
WITHIN PROGRAM
GRADE
LEVEL(S)
TAUGHT
SUBJECT(S)
AREA
TAUGHT
MA LICENSE INFORMATION
License Title, Type, Grade Level,
License Number, Expiration Date
CRITERION 11.5
DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION RELATED SERVICES STAFF ROSTER
AGENCY NAME:________________________________________________________
PROGRAM NAME:______________________________________________________
NOTE: List all staff providing or supervising the provision of related services whose services require a Massachusetts Professional License
(including consultants) in alphabetical order. Enter one staff name per line and group according to UFR#.
UFR
#
NAME
POSITION TITLE WITHIN
PROGRAM
MA LICENSE, REGISTRATION OR CERTIFICATION
TYPE, NUMBER AND EXPIRATION DATE
CRITERION 11.6
UFR #
101
102
103
104
105
107
108
109
111
112
113
114
115
116
117
118
119
120
DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION MASTER STAFF ROSTER
AGENCY NAME: __________________________________
PROGRAM NAME: __________________________________
DATE OF SUBMISSION: ____________________________
NOTE: One staff name per line; this master staff roster must indicate all FTE’s that matches the last approved budget.
FIRST AND LAST
NAME OF
Total POSITION TITLE
PERSON
*JUSTIFICATION FOR ALL
FTE(s)
WITHIN
CURRENTLY IN
DISCREPANCIES FROM THE LAST
UFR Title
PROGRAM
POSITION
APPROVED PROGRAM BUDGET
(NOTE IF
VACANT)
Program Function Manager
Program Director
Assistant Program Director
Supervising Professional
Physician
Registered Nurse/ Master’s
Registered Nurse
Licensed Practical Nurse
Occupational Therapist
Physical Therapist
Speech / Language
Pathologist, Audiologist
Dietician/Nutritionist
Special Education Teacher
Teacher
Day Care Director
Day Care Lead Teacher
Day Care Teacher
Day Care Assistant
Teacher/Aides
CRITERION 11.6
121
122
123
124
125
126
127
130
Psychiatrist
Psychologist – Doctorate
Clinician
Social Worker - LICSW
Social Worker - LCSW
Social Worker - LSW
Licensed Counselor
Counselor
131
Case Worker/Manager –
Master’s
132
133
134
135
136
137
138
201
202
206
Case Worker/Manager
Direct Care Program Staff
Supervisor
Direct Care/Program Staff III
Direct Care / Program Staff II
Direct Care/Program Staff I
Program Secretarial / Clerical
Program Support –
Housekeeping, Cook,
Maintenance, Janitorial,
Groundskeeper, Driver
Direct Care Consultant
Temporary Help
Sub-Contract Direct Care
Massachusetts Department of Elementary and Secondary Education
Program Quality Assurance Services
Form 1: NOTIFICATION / REQUEST FOR PRIOR APPROVAL OF SUBSTANTIAL CHANGES
WITHIN A PRIVATE SPECIAL EDUCATION SCHOOL PROGRAM
Date of this notice: ______________
Directions: All Private Special Education School Programs must complete page 1 of this form and attach to it a narrative description
addressing the applicable Notification or Request for Prior Approval of the substantial change(s). Include in the narrative the program’s
rationale for such change(s). Also include the required corresponding documentation listed on pages 2-3, and any other information that the
program believes justifies such request(s). Please consult pages 4-5 of this form for Guidance.
Fax or send this notice to: Director, Program Quality Assurance Services, Massachusetts Department of Elementary and Secondary
Education, 75 Pleasant Street, Malden, MA 02148-4906 – Fax: 781-338-3710
Pursuant to 603 CMR 28.09(5)(c), this private special education school program is hereby providing written notification / requesting prior
approval from the Department for the following reason(s):
NOTIFICATION TO ESE REQUIRED: Note the applicable specific timeline required for each notification
Immediate notification for:
___
unexpected building change as the result of an emergency
___
change in program’s financial status that impacts either the health and safety of students or the service delivery to students
___
closure of a program
15 working days notification for:
___
each 10% decrease in enrollment of students based on the last approved ESE Program Budget
___
change in program’s ownership
___
change in program’s name
___
vacanc(ies) in approved staff positions not filled by another appropriately licensed or waivered staff person, and that have a direct
impact on the service delivery to students
PRIOR APPROVAL FROM ESE REQUIRED BEFORE CHANGES MAY OCCUR:
___
changes to school building(s)/physical facilities that are not due to an emergency, but are related to relocation and/or expansion of
building(s)
___
changes made by the school to ESE required policies and procedures that result in continued adherence to regulatory requirements
___
request to increase or decrease the ages of the students being served
___
request to change or add gender of students being served
___
each 10% increase in enrollment of students based on the last approved ESE Program Budget
___
adding, eliminating, or changing staff positions
Private School Program Agency: ________________________________________________________________________
Address: ______________________________________________________________ Telephone: (__) ___________________
Name of Program: ______________________________________
Program Contact Person: __________________________
E-mail Address of Contact Person: ____________________________
Telephone of Contact Person: (__) __________________
Address of Program: _________________________________________ Telephone: ( ) _______________________________
____ Day School OR ___ Residential School
Name of Program Director: ______________________________ Signature:
___________________________________________DEPARTMENT OF ELEMENTARY AND SECONDARY
EDUCATION ACTION
APPROVAL STATUS:  Receipt Acknowledged on:
 Approved on:
 Denied on:
Received by ESE on:
All required documentation received on: ________________________
Request for Change Approved on: ____________________ Request for Change Denied on: ______________________(Reason attached.)
___________________________________
(Liaison, Program Quality Assurance)
_____________________________________
(Supervisor, Program Quality Assurance)
______________________________________
(Director, Program Quality Assurance)
Private School Program Staff Completing Page 1 of this form can review the
checklist below to ensure that information submitted to the Department
is complete and that it responds to all Form 1 information requirements.
Necessary Information Required for Form 1’s
NOTIFICATION:
Required documentation for the monitoring criteria listed below can be found at
http://www.doe.mass.edu/pqa/review/psr/instrument.doc
IMMEDIATE NOTIFICATION IS REQUIRED
Unexpected building change as the result of an emergency
Approvals, Licenses, Certificates of Inspection (criteria 2.2)
EEC Licensure if applicable (criteria 2.3)
Physical Facility/Architectural Barriers (criteria 13.4)
Notification to parents/guardians and responsible school districts
Anticipated return date to original location
Change in program’s financial status that impacts either the health and safety of students or the service delivery
to students
Current Student Roster (criteria 8.5)
Staffing for Instructional Groupings (criteria 10.1)
Teacher Roster (Special Education Teachers and Regular Education Teachers) (criteria 11.4)
Master Staff Roster (criteria 11.6)
Closure of a program
Current Student Roster (criteria 8.5)
Written notification sent to funding sources
Written notification sent to parents/guardians
Date program is expected to close
Transition status/plan for all students currently enrolled regarding new placements sought/secured
Student Record transfer plan for all students enrolled and for all prior students
Weekly or monthly updates to ESE on the Transition status/plan for all students enrolled
Weekly or monthly updates to ESE on the Student Record transfer plan for all students
15 WORKING DAYS NOTIFICATION IS REQUIRED
Each 10% decrease in enrollment of students based on the last approved ESE Program Budget
Current Student Roster (criteria 8.5)
Staffing for Instructional Groupings (criteria 10.1)
Age Range (criteria 10.2)
Teacher Roster (Special Education Teachers and Regular Education Teachers) (criteria 11.4)
Related Services Staff (criteria 11.5)
Master Staff Roster highlighting positions that have been temporarily eliminated or reduced due to decrease in student enrollment,
but that still meet approved staff to student ratios (criteria 11.6)
Number of students currently enrolled in the program
Last approved Program Budget including number of students ESE has approved for enrollment
Change in program’s ownership
Master Staff Roster (11.6)
Organizational structure (criteria 11.9)
Change in program’s name
Organizational structure (criteria 11.9)
Vacanc(ies) in approved staff positions not filled by another appropriately licensed or waivered staff person that
have a direct impact on the service delivery to students
Master Staff Roster (criteria 11.6)
Notification letter sent to funding public school district(s) of students affected by vacanc(ies)
Efforts school is making to fill vacanc(ies)
Alternative methods for provision of services
Necessary Information Required for Form 1’s:
PRIOR APPROVAL:
Required documentation for the monitoring criteria listed below can be found at
http://www.doe.mass.edu/pqa/review/psr/instrument.doc
Changes to school building(s)/physical facilities that are not due to an emergency, but are related to relocation
and/or expansion of building(s)
Approvals, Licenses, Certificates of Inspection (criteria 2.2)
EEC Licensure if applicable (criteria 2.3)
Physical Facility/Architectural Barriers (criteria 13.4)
Library/Resource Room (criteria 13.7)
Expected date construction will begin and will be completed and the impact on students, if any
Expected date of onsite visit from ESE liaison
Written assurance that students will not use the building until the Form 1 is approved by ESE
Changes made by the school to ESE required policies and procedures that result in continued adherence to
regulatory requirements
Copy of program’s proposed policy clearly identifying all changes to ESE previously approved policy
Criteria number in ESE monitoring booklet and/or regulation number
Method of dissemination to parents/guardians and funding sources after new and/or revised policy is approved by ESE
Request to increase or decrease the ages of the students being served
Program and Student Description (the 1st 5 bullets of criteria 1.2)
Staffing for Instructional Groupings (criteria 10.1)
Age Range (criteria 10.2)
Teacher Roster (Special Education Teachers and Regular Education Teachers) (criteria 11.4)
Ages currently approved to serve
Ages proposing/requesting to serve
Request to change or add gender of students being served
Program and Student Description (the 1st 5 bullets of criteria 1.2)
Staffing for Instructional Groupings (criteria 10.1)
Age Range (criteria 10.2)
Teacher Roster (Special Education Teachers and Regular Education Teachers) (criteria 11.4)
Genders currently approved to serve
Genders proposing/requesting to serve
Each 10% increase in enrollment of students based on the last approved ESE Program Budget
Current Student Roster (criteria 8.5)
Staffing for Instructional Groupings (criteria 10.1)
Age Range (criteria 10.2)
Teacher Roster (Special Education Teachers and Regular Education Teachers) (criteria 11.4)
Related Services Staff Roster (criteria 11.5)
Master Staff Roster highlighting additional positions required to meet approved staff to student ratios resulting from increased
student enrollment (criteria 11.6)
Description of physical facility including how it will accommodate an increase of enrolled students (criteria 13.2)
Number of students currently enrolled in the program
Last approved Program Budget including number of students ESE has approved for enrollment
Number of students by which enrollment will increase
Adding, eliminating, or changing staff positions
Current Master Staff Roster (criteria 11.6)
Proposed Master Staff Roster (criteria 11.6)
Written notification that will be sent to funding sources once change has been approved by ESE
Guidance for Completing Form 1: Notification/Request For Prior Approval of Substantial
Changes Within A Private Special Education School Program
The Department of Elementary and Secondary Education (ESE) has developed this written guidance to private special education
school programs in order to clarify reporting requirements for certain changes to its program(s) that are proposed and/or
unexpected, as well as the supporting documentation that must be submitted with the Form 1. All private special education
school programs seeking to make changes to its currently approved program(s) must complete a Form 1: Notification/Request For
Prior Approval of Substantial Changes Within A Private Special Education School Program. All private special education school
programs must attach a narrative description that directly pertains to the school’s notification or request for prior approval of the
substantial change(s). The narrative must include a rationale for such change(s). All private special education school programs
must submit the required documentation referenced on pages 2 and 3 of this form. The applicable monitoring criteria that relates
to that required documentation can be found at http://www.doe.mass.edu/pqa/review/psr/instrument.doc. Please note that the
checklist has been developed as a tool for your school program to use, but is not required to be completed by your school
program. While the private special education school programs do not need to complete nor submit the checklist, it is
recommended that all schools refer to the documentation requirements in order to determine the appropriate documentation that
needs to be submitted with the Form 1. It is important for the school to submit any other information it believes justifies such
request(s).
ESE is requiring private special education school programs to make immediate notification under the following circumstances:
 An unexpected building change as the result of an emergency. This means any changes to a building (school or residence)
due to unexpected circumstances such as a fire or flood. It is important for the school to clearly and completely describe the
change, the impact of the change on enrolled students, the school’s plan to address the change and to submit the required
documentation indicated on page 2 of the checklist.
 A change in the program’s financial status that impacts either the health and safety of students or service delivery to
students. If, due to changes in the financial status of a school, a school can no longer provide the required staffing to
maintain appropriate supervision of students and/or provide services to students as specified on their IEP’s, it must make
immediate notification to ESE and provide the required documentation indicated on page 2 of the checklist. The school
must describe its current financial status and the manner in which it will address the financial issues as well as its written
plan for ensuring the health and safety of students and/or provision of IEP services.
 Closure of a program. If, for whatever reason, a school needs to close suddenly or if a school is planning to close by a
specified date, it must immediately notify ESE along with providing the required documentation on page 2 of the checklist.
It is important for the school to develop and submit to ESE a written transition plan for all students enrolled in the school.
This plan must include the school’s outreach and collaboration with sending public school districts and other funding
sources and the steps the school will take to ensure all students transition smoothly to an appropriate, alternate placement.
ESE is requiring private special education school programs to notify ESE within 15 working days of the following circumstances:
 Each time there is a 10% decrease in enrollment of students based upon the number of students to be served by the school
as indicated on the last ESE approved Program Budget. The school must describe how it is continuing to meet the needs of
enrolled students and submit required documentation as indicated on page 2 of the checklist.
 A change in the program’s ownership. If another individual or agency will assume ownership of the program it is important
for the school to describe how this transition will take place and (if any) the impact this change of ownership may have on
the structure of the school, its staffing and/or service delivery to students. A master staff roster and an organizational chart
clearly indicating any changes to the staffing and/or structure of the school must be submitted as indicated on page 2 of the
checklist.
 A change in the program’s name. If the agency wishes to change the name of the program, the school must submit an
organizational chart clearly indicating any changes to the staffing and/or structure of the school as indicated on page 2 of
the checklist.
 Vacancies in approved staff positions not filled by another appropriately licensed or waivered staff person that have a direct
impact on the service delivery to students. It is important to note that notification must be made to ESE only if the vacancy
results in students not receiving services as indicated on their IEP’s. The school must clearly describe its alternative
methods for providing these services to students while attempting to fill any vacant positions. While the school is able to
temporarily fill a vacant position with a substitute teacher, it must notify ESE if substitute teachers are being used and must
continue to document its efforts to fill the position with an appropriately licensed staff person. Of additional note is that
schools must notify the sending public school districts of staff vacancies only for those students affected by the vacancy and
not receiving services as indicated on their IEP’s. A master staff roster addressing any changes made to staffing of the
school due to such a vacancy must be submitted as indicated on page 2 of the checklist.
ESE is requiring prior notification and approval for the following circumstances:
 Changes to school building(s)/physical facilities that are not due to an emergency, but are related to relocation and/or
expansion of buildings. These changes represent changes to buildings/physical facilities that are planned and can include
renovations to an existing building or constructing a new building. The school must submit all required documents as
indicated on pages 2-3 of the checklist. It is important to note that ESE will thoroughly review this request along with all
supporting documentation and will render an approval based upon the rationale provided and documentation submitted.
Approval of this request will not result in any type of rate adjustment at the time of approval of the Form 1. If the school
wishes to apply for approval of a rate adjustment directly resulting from a building change it may do so upon eligibility
through the program reconstruction process. Approval of a Form 1 for building changes will not automatically result in ESE
approval of a reconstruction application. ESE reserves the right to review all changes made and the impact such building
changes may have on the school’s rate upon the school’s submission of a program reconstruction application.
 Changes made by the school to ESE required policies and procedures that result in continued adherence to regulatory
requirements. These changes represent changes to ESE approved policies and procedures initiated by the school. Schools
do not need to notify ESE of changes to existing policies and procedures that ESE is mandating. If a school determines that
changes to an existing policy/procedures are necessary, it must clearly identify and outline any and all changes to its
existing policy and submit a copy of the revised policy/procedures along with its Form 1 submission. The school must
describe the anticipated impact the change will have on students (such as changes to behavior management policies and
procedures) as well as staff (such as changes to personnel policies and procedures). The school must also describe its
method of dissemination of the changes to any policies and procedures once approved by ESE. The school must inform
ESE of its plan to communicate approved changes in policies and procedures to parents/guardians and funding sources.
 Request to increase or decrease the ages of the students being served. The school must submit all required documentation as
indicated on page 3 of the checklist. It is important that the school fully describe in its Form 1 submission how it is prepared
to meet the needs of either younger or older students in terms of student groupings, staffing and curriculum.
 Request to change or add gender of students being served. The school must submit all required documentation as indicated
on page 3 of the checklist. The school must clearly describe any special provisions it must make in order to successfully
accommodate and serve students of a different gender.
 Each time there is a 10% increase in enrollment of students based upon the number of students to be served by the school as
indicated on the last ESE approved Program Budget. The school must describe how it is continuing to meet the needs of
enrolled students and submit required documentation as indicated on page 3 of the checklist. ESE must be informed of staff
changes resulting from an increase in student enrollment and the school’s plan for continuing to meet all approved student
to staff ratios.
 Adding, eliminating or changing staff positions. ESE recognizes there may be a need for schools to make changes to staff
positions in order to be able to meet the ongoing needs of students enrolled in the program. The school must provide ESE
with a detailed rationale for any proposed changes in staffing and must submit all required documentation as indicated on
page 3 of the checklist. It is important to note that ESE will thoroughly review this request along with all supporting
documentation and will render an approval based upon the rationale and documentation submitted. Approval of this request
will not result in any type of rate adjustment at the time of approval of the Form 1. If the school wishes to apply for
approval of a rate adjustment directly resulting from changes to staffing, it may do so upon eligibility through the program
reconstruction process. Approval of a Form 1 for changes to staffing will not automatically result in ESE approval of a
reconstruction application. ESE reserves the right to review any and all staffing changes made by the school and the impact
such staffing changes may have on the school’s rate upon the school’s submission of a program reconstruction application.
With its Form 1 submission, the school must also describe how it will provide written notification to all funding sources
once the change in staffing has been approved by ESE.
The Massachusetts Department of Elementary and Secondary Education
Program Quality Assurance Services
Form 2:
PUBLIC AND PRIVATE DAY OR RESIDENTIAL SCHOOL PROGRAM
INCIDENT REPORT
Directions: Complete Page 1 of this form. Attach a narrative description of 1) the specific incident described below,
2) the steps the school has taken to respond to this incident, and 3) the persons or agencies notified of such incident.
Provide one incident report per student. Please review the “Checklist of Necessary Information for Incident Reports” on Pages 2 and
3 describing the documentation and action steps ESE expects for specified incidents.
Fax or send this Form 2 to: Director, Program Quality Assurance Services, Massachusetts Department of Elementary and Secondary
Education, 350 Main Street, Malden, MA 02148-5023 – Fax: 781-338-3710
Public/Private School Name: ___________________________________ Student’s Name: ____________________________________
Address: ______________________________________________________________________________________________________
Name of Program: ______________________________________
ESE Program Code Number ( 4-Digit):________
Program Contact Person: ____________________________
Telephone: (
Address of Program: _____________________
E-mail Address of Contact Person:_________________
Day School
OR
Massachusetts Student
OR
Name of Program Director: ______________________________
) ________________________
Residential School
Out-of-State Student
Signature: _______________________________
Date of this Incident Report: ____________________________________Date of Incident: ______________________
Pursuant to applicable regulations and requirements this school is hereby providing immediate written notification to ESE
For Any Student (Massachusetts and Out-of -State Students):
The death of any student (Contact your assigned PQA Liaison or the “Liaison of the Day” 781-338-3700)
The filing of a 51-A report with DCF OR a complaint filed with the Disabled Persons Protection Commission, against the school or a school
staff member, for abuse or neglect of any student
Any action taken by a federal, state, or local agency that might jeopardize the school’s approval with ESE
Any legal proceeding brought against the school or its employee(s) arising out of circumstances related to the care or education of any of its
students regardless of state of residency
For Massachusetts Students Only:
The hospitalization of a Massachusetts student (including out-patient emergency room visits) due to physical injury at school or previously
unidentified illness, accident or disorder which occurs while the student is in the program
Massachusetts student injury resulting from a motor vehicle accident during transport by school staff (including contracted staff) which
requires medical attention
Massachusetts student run away
Emergency termination of a Massachusetts student under circumstances in which the student presents a clear and present threat to the health
and safety of him/herself or others pursuant to 18.05(7)(d)
Any other incident of a serious nature that occurs to a Massachusetts student
NOTE: The school must also provide immediate written notification to the responsible school district and to the parent/guardian for any
incident described above, for both Massachusetts and Out-of-State Students.
Form 2 Revised 08/04/15
Public and Private School Staff Completing Page 1 of this form should review the
“Checklist of Necessary Information for Incident Reports” below to ensure that information submitted to ESE is
complete and that it responds to all incident reporting information requirements.
Pages 2 and 3 to be completed by ESE only:
INTERNAL RECORD OF
DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION ACTION:
Incident Report Received by ESE on:____________ Incident Report Reviewed:______________________
ACTION TAKEN:
____Incident Report reviewed, and school’s action plan determined to be acceptable
____Follow-up telephone inquiry or e-mail contact with the program made on: __________________
____Inquiry made by: _______________________
(Summary of telephone inquiry or e-mail contact attached.)
____ Onsite visit pursuant to this report conducted on: ____________________ Conducted by: ___________________________
Site visit report and any notice of required corrective action issued to program on: _________________ (Copy attached)
______________________________________
(Liaison, Program Quality Assurance Services)
______________________________________
(Supervisor/Designee, Program Quality Assurance Services)
Checklist of Necessary Information for Incident Reports:
FOR ANY STUDENT
Required Documentation
Received
Acceptable
Not
Submitted
or
Unacceptable
Narrative description detailing the circumstances of the incident
Must include events preceding incident, incident, and outcomes.
Who? What? When? Where? How? Why?
Specific procedure that staff followed is clearly described
Required notifications provided
Date, time and by whom. Examples: DCF, DPPC, EEC, ESE, Parents/Guardians, LEA,
other involved agencies such as DMR and DMH
Death of any student:
Police/Coroner Investigation? Autopsy Report?
The filing of a 51A report with DCF or a DPPC complaint alleging abuse or neglect
of any student, against the school or a school staff member:
Description of incident and actions taken by the school thus far, as well as actions
planned to be taken by the school (school conducting investigation; DCF or DPPC
conducting investigation; police investigating)?
Copy of Internal Investigation Report?
Copy of Police Report?
Description of any disciplinary action the staff member received?
Was the report screened in or out by DCF or DPPC? Copy of DCF or DPPC Report?
Follow-up by school post investigation – were steps taken by school appropriate?
Action taken that might jeopardize school’s approval with ESE OR
Any legal proceeding brought against the school or its employee(s) arising out of
circumstances related to the care or education of any of its students:
Examples include change in EEC licensure status, Intake frozen, Investigation by
another state agency, complaints or ongoing concerns from sending public school
districts; and the arrest of a staff member.
Report describes incident and actions taken by the school thus far, as well as actions
planned to be taken by the school?
Investigation reports to determine outcome?
Additional Information:
Form 2 Revised 8/4/15
Checklist of Necessary Information for Incident Reports:
FOR A MASSACHUSETTS STUDENT
Required Documentation
Received
Acceptable
Not
Submitted
or
Unacceptable
Narrative description detailing the circumstances of the incident
Must include events preceding incident, incident, and outcomes.
Who? What? When? Where? How? Why?
Specific procedure that staff followed is clearly described
Required notifications provided
Date, time and by whom? Examples: DCF, DPPC, EEC, ESE, Parents/Guardians, LEA,
other involved agencies such as DMR and DMH
Out-patient emergency room visit or hospitalization of a Massachusetts student as
a result of physical illness or injury;
OR
injury of a Massachusetts student during school-related motor vehicle accident that
required medical attention;
Additionally, if motor vehicle accident –
Were the details of the accident provided, including numbers of students and staff in the
motor vehicle, circumstances under which the accident occurred, condition of the
individuals involved in the accident?
Copy of police report?
Drivers license information of staff member?
Transportation training of staff member?
Any follow-up conducted by the school regarding details of the accident being
communicated to the school community?
Whenever a Massachusetts student runs away:
What were the circumstances of the runaway (on independent time; climbed out window
without knowledge of staff)?
If known, when did student return?
Where was student found and by whom?
If did not return notification of liaison by phone of the details
Staff to student ratio – what was staff assigned to student doing at the time of the
runaway?
What precautions were taken for student to return to school (hospital screening, time out
space, restrictions at school, re-entry plan)?
What specific steps the school will take to prevent future runaway occurrences?
Emergency termination of a Massachusetts student consistent with 603 CMR
28.09(12)(b) and 18.05(7)(d):
Description of clear and present danger?
Written termination summary explaining the reasons for emergency termination?
Efforts the school has made to maintain the student until the LEA is able to locate an
appropriate placement?
Copy of written termination notification sent to the school district/parent?
Any other incident of a serious nature that occurs to a Massachusetts student:
Examples include police involvement, community involvement and media coverage.
Report describes incident and actions taken by the school thus far, as well as actions
planned to be taken by the school?
Investigation reports to determine outcome?
Additional Information:
Form 2 Revised 8/4/15